Manual wheelchair training for individuals with chronic and progressive conditions: A critical realist approach to improving practice

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Effective training can improve independence and engagement in meaningful activities and reduce injury risk, caregiver burden and reliance upon healthcare services. However, not all training contexts yield positive outcomes for all MWC users. Using a realist approach, this study describes the development of middle range theories to provide insight into the contexts and mechanisms that underpin successful manual wheelchair training outcomes. Method A realist approach synthesised evidence from primary studies (n = 47) and stakeholder interviews (n = 17) to explore the contexts, mechanisms and outcomes underlying manual wheelchair training effectiveness. Retroductive analysis was used to build and refine initial program theories to explain why and under what circumstances a MWC training intervention may be working. To enhance explanatory power, we considered existing rehabilitation and learning theories, leading to the development of middle range theories that offer generalisable causal explanations of how and why MWC training works. Results Five Middle-Range Theories (MRTs) were developed. MRT 1: Resources and structured guidance enhances user confidence; MRT 2: The delivery of person-centred, goal-directed training enhances motivation, user acceptance and engagement in MWC training; MRT 3: Training in safe and relevant environments facilitates MWC user confidence and willingness to engage in training. MRT4; Training in environments with positive social attitudes towards wheelchair use enhances psychological safety and acceptance of wheelchair use. MRT 5; Including peers, peer trainers and care partners in MWC training is motivational and supports self-efficacy in wheelchair use. Collectively these MRTs reflect the importance of a well -resourced, user-centred, socially supportive and contextually relevant approach to MWC training. Discussion/Implications This research highlights the need for system-wide reform to improve MWC training for individuals with chronic and progressive conditions. Key priorities include addressing funding disparities, integrating services across sectors, delivering training in authentic, inclusive environments, providing flexible, person-centred approaches, building workforce capacity and embedding accountability into MWC training. Manual wheelchair training chronic conditions progressive conditions best practice realist approach Figures Figure 1 Figure 2 Figure 3 Background Manual wheelchair (MWC) training plays a critical role in promoting safe, confident and efficient wheelchair use. When delivered effectively, training can improve mobility and confidence, support independence and enable participation in meaningful activities, ultimately enhancing quality of life (1, 2). It helps reduce the risk of upper limb injuries related to overuse or incorrect propulsion, as well as falls (3–5). Training also lessens caregiver burden and reduces reliance on healthcare services, leading to broader social and economic benefits. Despite these benefits, access to MWC training is often limited to certain populations, such as individuals with spinal cord injury. Those who begin using a wheelchair part- or full-time due to gradual functional decline associated with chronic or progressing conditions, are frequently excluded from training opportunities (6) or receive training that is inconsistent, brief (7–11) and may not always meet the needs or desired outcomes of users (12). Several systematic barriers contribute to this problem, including an inadequate number of appropriately trained personnel (13), competing priorities of the MWC trainer workforce (6–9, 11), wheelchair service providers operating in silos without established referral networks and links between providers (6), short inpatient rehabilitation stays and a lack of funding and resources for quality MWC training provision (6–9, 11). Recommendations for MWC propulsion education (14) and general guidelines for wheelchair training exist (15) and aim to support positive training outcomes for all MWC users. However, these are often generic and not tailored to the diverse and evolving needs of all wheelchair users, including those with chronic or progressive conditions who may present with unique physical, cognitive and emotional challenges. They also offer limited guidance on adapting content to different contexts or user needs. Similarly, standardised, evidence-based training protocols exist (16) yet they frequently focus strongly on physical skill acquisition (17) and do not attend to emotional, cognitive and psychological needs of individuals with complex or progressive conditions nor do they provide practical detail on delivering person centred training in varied settings. This oversight is problematic as the potential positive outcomes of MWC training are not being fully realised (17), highlighting the need to improve and rethink how MWC training is delivered, particularly for people commencing MWC use due to chronic or progressive conditions. A critical realist approach is one way to interrogate these challenges (18). Realist research is based on the premise that outcomes arise from underlying mechanisms, often which cannot be seen, and operate differently depending on the context (18). As such, interventions may work in one setting but not in another, depending on the contextual conditions and mechanisms they trigger. A realist synthesis applied this logic to systematically develop and refine program theories, which are evidence-informed explanations of how and why an intervention works, from whom and in what contexts (19). While a realist synthesis primarily draws upon literature to build these theories (19), it may also incorporate stakeholder interviews to test and refine theories and to ensure their relevance to practice (20). This iterative process strengthens the explanatory power and practical relevance of program theories by grounding them in both existing evidence and lived experience (21–24). Programme theories are typically expressed as a Context-Mechanism-Outcome configuration (CMOc), a heuristic that prompts researchers to consider how specific contexts enable or constrain mechanisms to produce particular outcomes. The iterative development of program theories provide more transferrable, practice ready explanations of what works, for whom and in what circumstances (25). Given the complexity of MWC training delivery and the diversity of user needs, particularly among individuals with chronic or progressive conditions, a deeper understanding is needed of how, why and under what circumstances MWC training supports meaningful outcomes. This research uses a realist synthesis to develop and refine program theories that can inform more tailored and effective training approaches. Research question: What works, for whom, in what contexts and why, in manual wheelchair training for those commencing wheelchair use due to chronic or progressive conditions? Methods Methodological approach A critical realist approach was adopted for this research to explore of how, why and under what circumstances MWC training works by examining the interactions between contexts, mechanisms and outcomes (19). Early program theories were initially developed based on practice knowledge and clinical experience, then refined through a systematic review of literature to inform the development of initial program theories (IPTs) related to MWC training. These theories were further developed and refined through interviews with MWC users with chronic or progressive conditions and trainers who had experience working with this population. Insights from all sources enabled iterative shaping and testing of program theories, allowing for a more nuanced understanding of what works for whom and in what circumstances, specifically for individuals commencing wheelchair use due to a chronic or progressive condition. To further strength the explanatory power of these theories, relevant rehabilitation and learning theories were incorporated to guide the refinement of IPTs into middle range theories (MRTs). This theoretical grounding also informed the development of recommendations tailored to the needs of this population. Figure 1 outlines the overarching process of program theory development. The RAMESES publication standards for realist syntheses were followed (26) in this research paper. Data Collection Literature A systematic search strategy was conducted to identify papers on manual wheelchair training, first in July 2022 and updated in September 2023 and May 2025. Papers solely focused on paediatric or abled bodies users simulating as wheelchair users, were excluded to enable literature to be nuanced to wheelchair training for adults/older adults. This full search strategy has been published elsewhere (27). Ninety-seven papers were assessed for relevance , i.e., could the paper add to the developing program theories? and rigor i.e., was the method used to generate data plausible for answering the research question and were the findings well supported by data collected (19). Table 1 details the inclusion and exclusion criteria. Forty-eight papers met relevance and rigor requirements and were included for data extraction. Figure 2 illustrates the PRISMA flowchart for study selection. Table 1. inclusion and Exclusion criteria Inclusion Criteria Participant group: Manual Wheelchair users and/or their caregivers who were commencing wheelchair use as adults Papers where only some participants met the inclusion criteria (on the basis that they may have applicability to those commencing wheelchair use as adults Papers which had a mix of powered and manual wheelchair users Intervention/Concept: Wheelchair training program describing outcomes (must have sufficient detail to identify Contexts, Mechanisms and Outcomes to be able to contribute meaningfully to theory development). MWC user, carer or trainer perspectives of manual wheelchair training where Contexts, Mechanisms and Outcomes of wheelchair training can be identified and have sufficient depth to contribute meaningfully to theory development. Paper type: Articles in English Published after 1995 Exclusion criteria Participant group: Able-bodied persons simulating wheelchair users, including clinicians and students Paediatric wheelchair users Intervention/concept: Exclusive focus on exercise programs designed to strengthen muscles or improve fitness for wheelchair use Exclusive training of powered wheelchair use Paper Type: Any reviews of literature ie., scoping reviews, systematic reviews, literature reviews, summary/position papers. Surveys that are not specific to one wheelchair training program Wheelchair training protocols or any training programs where outcomes have not been measured Papers that do not provide sufficient information to identify at least two of the following; context, mechanism, outcome. Interviews Six manual wheelchair users who commenced MWC use as an adult due to chronic, or progressive conditions, along with 11 trainers who delivered MWC training to adults with a range of conditions, including neurological disorders, amputations, orthopaedic injuries and Spinal Cord Injury (SCI) completed individual semi-structured interviews online via Zoom (Zoom Video Communications Inc.) over an eleven-month period from January 2024 to November 2024. Trainers were included if their training experience extended beyond SCI and included individuals with chronic or progressive conditions, reflecting the study’s aim to explore perspectives underrepresented in the literature. Separate interview guides were developed for MWC trainers and users, designed to explore explanatory mechanisms for wheelchair training outcomes based on existing experience, literature and stakeholder perspectives (28). The interview guide used in this study was published previously (6) and was piloted with a MWC trainer and user known to the research team, was and refined based on feedback. Interview guides continued to be iteratively refined throughout the data collection process to deepen the exploration of explanatory mechanisms (28). Full details on recruitment and data collection have been previously published (6). Data extraction Data from qualitative interviews and research papers were extracted. Demographic information from MWC user/trainers, along with study characteristics from research papers (i.e., author name, publication year, country of publication, types of paper, type of participants, intervention) were recorded. An excel spreadsheet template was used to extrapolate contextual factors, mechanisms and outcomes from both qualitative interviews and research papers. Contexts were identified by examining the methodologies of included papers and participant accounts (29). To categorise the identified contexts, the Environmental Factors chapters of the World Health Organisation’s International Classification of Functioning (ICF) were used. This includes five key chapters; products and technology, natural environment and human made changes to the environment, support and relationships, attitudes and services, systems and policies. This framework is widely recognised and provides a structured approach for categorising environmental influences on human functioning, making it well-suited to identify how different contextual elements may activate or constrain mechanisms. Mechanisms, which are often unobservable, were inferred from participant’s explanations of why they believed change occurred, including emotional (i.e., motivation), cognitive (i.e., self-efficacy), or social responses (i.e., peer encouragement) to training. In research papers, mechanisms were identified in authors’ interpretations, discussion sections and descriptions of the intervention process that suggested why certain outcomes were observed in specific outcomes (20, 29). Outcomes referred to the effects or changes resulting from the intervention and were drawn from reported changes in outcomes as described in study results and as reflected on by participants during interviews. Outcomes included behavioural, psychological, functional or health related outcomes. Examples of extracted data can be found in Table 2. Table 2. Examples of extracted under Contexts-Mechanisms-Outcomes Examples Context Products and Technology Biofeedback provided through technology, wheelchair simulators, tablet-based training, spotter straps, wheelchair set up, wheelchair anti tip bars. Services, Systems and Policies Organisational/institutional factors of the health services implementing an intervention (ie., the follow through of training across healthcare settings)financial resources (ie., high resourced or low resources settings), regulations/policies or procedures influencing intervention delivery. Attitudes Stereotypes, attitudes of trainers, peers and family. Support and Relationships Social environment in which an intervention takes place, including peer led training, group training, presence of carers in training, inclusion of spotters and skills of the trainer. Natural environment and human made changes to the environment Physical environment in which an intervention takes place ie homes, community, hospitals, laboratories, online, simulated environments, training camps. Mechanism Psychological mechanisms: Ie., Increased confidence, improved self-efficacy, fear/anxiety reduction, motivation/level of engagement Social mechanisms: Ie., peer, instructor or family/caregiver support Cognitive mechanisms: Ie., Increased learning/understanding, increased coping ability, increased ability to process feedback. Physical mechanisms: Ie., changes in muscle strength, coordination or endurance, neuroplastic changes. Outcomes Increased propulsion efficiency, reduced pain, Increased mobility, increased community and social participation, increased engagement in activities of daily living, increased independence, safety. Stronger social supports/relationships, improved attitudes towards MWC use Increased confidence, Improved self-efficacy. Data Analysis Data obtained from the systematic search process and interviews were initially analysed separately. A retroductive analytical approach was used to develop context-mechanism-outcome configurations (30). This involved working backwards from observed outcomes to infer the underlying causal mechanisms that may have produced them in particular contexts (30). A total of 52 CMOcs were generated from the literature and 36 from the interview data. These were compared across data sources to identify demi-regularities, i.e., any recurring alignments or complimentary, but not universal patterns in how certain contexts and mechanisms tended to produce similar outcomes. This process brought the two analyses together and enabled integration of insights from the literature and interviews. CMOcs from both data sets were triangulated to ensure that theory development remained grounded in empirical evidence and the contextual experiences of MWC users and trainers. Triangulation also supported the refinement, validation and prioritisation of CMOcs into IPTs. Through this process, 16 IPTs were developed, representing early evidence-informed explanations of how manual wheelchair training might work, for whom and in what circumstance (19). Supplementary Material 1 details these IPTs and the data sources they were derived from. Microsoft Excel was used to record and track CMOcs and their contribution to IPT development. Existing theoretical frameworks relevant to rehabilitation and learning were also drawn upon to enhance the explanatory power of IPTs by supporting the interpretation of underlying mechanism in MWC training. Self-determination theory (31) helps explain how users become motivated to engage in wheelchair training when their needs for autonomy, competence and relatedness are supported. Situated learning theory (32) provides insight into how learning is most effective when embedded in authentic environments. Social cognitive theory (33) offered a lens to understand how individuals develop self-efficacy and confidence in their ability to perform wheelchair skills through mastery experiences, observational learning and social feedback. Social learning theory (34) contributed to understanding how users learn through observation and modelling, such as when working alongside peers or trainers. Finally, cognitive load theory (35), was used to understand how the complexity of tasks and the presentation of information can impact learning new or demanding wheelchair skills These theories helped guide the refinement of IPTs and supported the prioritisation of the most plausible theories while discarding those less strongly supported. This process facilitated the transition from initial program theories to five preliminary MRTs. Figure 3 Illustrates the refinement of an early theory through its development into an IPT and subsequently a MRT. Results Interview Data Seventeen people from four states and one territory of Australia, participated in semi structured interviews. Six were MWC users (4F, 2M), with an average age of 55.5 ± 14.74 years, with experience in MWC use ranging from three to over 15 years (average 6.25 ± 4.53). Reasons for MWC use included lower limb amputations (n = 3), multiple contributing conditions (n = 2) and post-polio syndrome (n = 1). Eleven were MWC trainers (9F, 2M) with experience in MWC training ranging from four to over 30 years. The majority were occupational therapists (n = 6), followed by peer wheelchair trainers (n = 3), an exercise physiologists (n = 1) and an allied health assistant (n = 1). The trainers predominantly provided their service to adult MWC users, including those with neurological conditions, amputations, orthopaedic injury and Spinal Cord Injury (SCI). All participants were assigned a pseudonym, which is used in reporting the findings. Full demographic details of participant groups have been reported in detail in a separate study (6). Literature The 47 included papers were published between 2001 and 2024 across 12 countries, largely from North America (United States = 16 and Canada = 17). Papers included Randomized Control Trials (RCTs) (n = 24); Pre and Post Design (n = 9); qualitative papers (n = 5), cohort studies (n = 5), mixed methods (n = 2) and case studies (n = 2). Diverse groups of MWC user cohorts included people with SCI, Multiple Sclerosis (MS), Cerebral Palsy, Osteoarthritis (OA), Stroke, amputations and other conditions and included male and females who were both relatively inexperienced in MWC use or were long term MWC users with many years of experience. A range of MWC training programs were provided across papers. Table 3 provides full details of study characteristics. Table 3 Study characteristics of included papers Author Publication Date Country of Publication Type of Paper Participant details Training Program Beaudoin et al., 2021 Canada Mixed Methods 19 participants (9M, 10F) Average age 45 years 14 years MWC experience Reasons for use include; MS, SCI, Amputation, spina bifida, other. Roulez avec confiance (RAC) OR Wheeling with Confidence Best et al., 2005 Canada RCT 20 participants (15M, 5F) Average age 49 years > 1 year MWC experience Reasons for use include; amputations, stroke, peripheral neurological disorder Wheelchair skills training program Best et al., 2016 Canada RCT 28 participants (22M, 6 F) Average age 48.7 years 13.6 years MWC experience Reasons for use include; MS, SCI, CP, other. Self-Efficacy Enhanced Wheelchair Training Intervention (WheelSee) Blouin et al., 2015 Canada Cohort Study 18 participants (16M, 2F) Average age 42.4 years 14.8 years MWC experience Reasons for use include; SCI Wheelchair Simulator with Haptic feedback Chaar & Archambault 2022 Canada Qualitative 6 participants (5M, 1F) Average age 56 years > 3 years MWC experience Reasons for MWC use; unspecified Wheelchair simulator using a sidewalk scenario Charlton et al., 2021 Australia Mixed Methods 11 participants (9M, 2F) Average age 58.7 years > 2 months MWC experience Reasons for use include; amputations Modified version of the wheelchair skills training program. Chen 2019 USA RCT 8 participants (7M, 1 F) Average age 47.5years 16 years MWC experience Reasons for use include; MS, SCI, CP Clinical Practice Guidelines for preserving shoulder function. Choi et al., 2020 Korea Pre and Post 4 participants (2M, 2F) Average age 47.2 years > 1 year MWC experience Reasons for use; SCI Training across six skills; ascending/descending low and high curbs and ascending and descending stairs. DeGroot et al., 2009 USA Cohort Study 9 participants (6M, 3F) Average age 36.8 years 10 years MWC experience Reasons for use; MS, SCI, CP, other Biomechanical efficiency training on a wheelchair treadmill, carpeted surface, ramp and cross slope. Desai et al., 2013 India Pre and Post design 13 participants (6M, 3F) Average age unknown Unknown years MWC experience Reasons for use; SCI Wheelchair skills training program Furmaniuk et al., 2010 Poland Pre and Post design 40 participants (40M) Average age 29.4 years > 5 years MWC experience Reasons for use; SCI Rugby skills group including muscle strength and endurance training and wheelchair skills. Garrett et al., 2011 USA Case Study 2 participants Average age unknown unknown years MWC experience Reasons for use; SCI Adapted wheelchair skills training program. Giesbrecht & Miller 2017 Canada RCT 18 participants (15M, 5F) Average age 66.1 years > 2 years MWC experience Reasons for use; unknown Enhancing Participation in the Community (EPIC Wheels)- monitored wheelchair training via a computer tablet. Giesbrecht & Miller 2019 Canada RCT 18 participants (13M, 5F) Average age 65 years > 2 years MWC experience Reasons for use; MS, SCI, amputation, OA, stroke Enhancing Participation in the Community (EPIC Wheels)- monitored wheelchair training via a computer tablet. Giesbrecht et al., 2015 Canada Pre and Post design 2 participants (2M) Average age 66 years 20 years MWC experience Reasons for use; SCI, amputation Enhancing Participation in the Community (EPIC Wheels)- monitored wheelchair training via a computer tablet Giesbrecht et al., 2015 Canada Qualitative 10 participants (7M, 3F) Average age between 55–85 years 4–60 years MWC experience Reasons for use; Unknown Giesbrecht et al., 2025 Canada RCT 50 participants (17 M, 33F) Average age 52 years 7.8 years MWC experience Reasons for use; Not stated TEAM Wheels- monitored wheelchair training via a tablet Han et al., 2024 Japan Cohort Study 12 participants (10M, 2F) Age not specified Years of MWC experience not specified Reasons for use not specified The use of sensors to help users visualise wheelchair operation techniques Kirby et al., 2001 Canada RCT 42 participants (10M, 32F) Average age 30 years 30 years MWC experience Reasons for use; SCI, amputation, able bodied persons Training in wheelie related skills Kirby et al., 2004 Canada Pre and Post design 24 participants- caregivers (9M, 15F) Average age 53.3 years > 1 years MWC caregiver experience Reasons for use of user; amputation, MSK conditions, SCI, stroke Wheelchair skills training program adapted for caregivers. Kirby et al., 2016 USA RCT 106 participants (101M, 5F) Average age 39 years 17.4 years MWC experience Reasons for use; SCI Wheelchair Skills Training Program Kirby et al., 2024 Canada RCT 27 participants- caregiver (6M, 6F) Average age caregiver 56.8 years > 1 years MWC caregiver experience Reasons for use of user; Stroke, amputation, other Remote training provided using the Wheelchair Skills Program Manual Version 5.1 for guide. Kotajarvi et al., 2006 USA Cohort Study 18 participants (16M, 2F) Average age 38.4 years 14 years MWC experience Reasons for use; SCI Biomechanical efficiency training with visual feedback Limroongreungrat et al., 2009 USA RCT 28 participants Average age 33.9 years unknown years MWC experience Reasons for use; SCI Wheelchair propulsion training with video feedback Liu et al., 2019 USA Qualitative 10 participants (6M, 4F) Average age 37.5 years 25.56 years MWC experience Reasons for use; spina bifida, SCI My Wheelchair Guide app MacPhee, 2004 Canada RCT 35 participants (26M, 9F) Average age 59 years > 1 years MWC experience Reasons for use; MSK and Neurological conditions. Wheelchair skills training program McClure et al., 2010 USA RCT 31 participants (21M, 10F) Average age 41.4 years Unknown years MWC experience Reasons for use; SCI Implementation of clinical practice guidelines "Preservation of Upper Limb Function Following Spinal Cord Injury" Miller et al., 2019 Canada RCT 18 participants (7M, 11F) Average age 66.2 years 4.3 years MWC experience Reasons for use; SCI, amputation, other Wheelchair Self-Efficacy Enhanced for Use (WheelSeeU) training program Morgan et al., 2017 USA Pre and Post design 6 participants (4M, 2F) Average age 38 years > 2 years MWC experience Reasons for use; SCI Wheelchair Propulsion biomechanical training Ozturk et al., 2011 Turkey RCT 24 participants (11M, 13F) Average age 33 years 8.85 years MWC experience Reasons for use; SCI, amputation, OA, CP, Polio, stroke, other Wheelchair Skills Training Program Park & Jung 2022 Korea RCT 24 participants (14M, 10F) Average age 33 years 2 years MWC experience Reasons for use; Stroke Modified Wheelchair skills training program Pellichero 2020 Canada Qualitative Research 11 participants (3M, 8F) Average age 64.6 years 4.8 years MWC experience Reasons for use; MS, SCI, amputation, OA, polio Wheelchair Self-Efficacy Enhanced for Use (WheelSeeU) training program Quinones-Uriostegui et al., 2017 Mexico Pre and Post design 12 participants (10M, 2F) Average age 35.3 years 5.6 years MWC experience Reasons for use; SCI WHO 8 step guidelines on the provision of manual wheelchairs in less resourced settings Rice et al., 2010 USA Case Study 1 participants (1M) Average age 35.6 years 11 years MWC experience Reasons for use; SCI Manual wheelchair propulsion training program using visual feedback Rice et al., 2013 USA RCT 27 participants (24M, 3F) Average age 40.4 years 17.9 years MWC experience Reasons for use; SCI Manual wheelchair propulsion training program using visual feedback Rice et al., 2015 USA RCT 14 participants (4M, 10F) Average age 40.4 years > 17 years MWC experience Reasons for use; MS Manual wheelchair propulsion training Rice et al., 2014 USA RCT 37 participants (28M, 9F) Average age 37 years Unknown years MWC experience Reasons for use; SCI Implementation of the Paralysed Veterans of America's Clinical Practice Guidelines for Preservation of Upper Limb Function Richter et al., 2011 USA Pre and Post design 31 participants (27M, 4F) Average age 34.1 years 15 years MWC experience Reasons for use; SCI, CP, other Biomechanical wheelchair propulsion training using biofeedback. Routhier et al., 2012 Canada RCT 39 participants (27M, 12F) Average age 46 years > 1 years MWC experience Reasons for use; MS, SCI, amputation, other French-Canadian version of the Wheelchair Skills Training Program Standal et al., 2008 Norway Qualitative Research 20 participants (16M, 4F) Average age 43 years > 1 years MWC experience Reasons for use; SCI, Neurological condition Wheels in Motion training program. Tasiemski, et al., 2021 Morocco Pre and Post design 19 participants (13M, 6F) Average age 33 years 24 years MWC experience Reasons for use; SCI, CP, polio, other Wheelchair Skills and Empowerment Camp Tasiemski et al., 2024 Poland Cohort Study 122 participants (88M, 34 F) Average age 34 years 2 years MWC experience Reasons for use: SCI Attendance at Active Rehabilitation Camps with focus on wheelchair skills Van Der Scheer et al., 2015 Netherlands RCT 16 participants (11M, 5F) Average age 54 years > 10 years MWC experience Reasons for use; SCI Low-intensity wheelchair propulsion training. Van Der Scheer et al., 2016 Netherlands RCT 29 participants (22M, 7F) Average age 56 years 18 years MWC experience Reasons for use; SCI Low-intensity wheelchair propulsion training Worobey et al., 2016 USA RCT 79 participants (69M, 10F) Average age 40.5 years 13.2 years MWC experience Reasons for use; SCI Wheelchair skills training program. Yeo & Kwon 2018 Korea RCT 24 participants (19M, 5F) Average age 35 years 2.85 years MWC experience Reasons for use; SCI Wheelchair skills training program. Yong Tai et al., 2015 USA RCT 18 participants (12M, 6F) Average age 34 years > 2 months MWC experience Reasons for use; SCI Learning three wheelchair skills; ramps, wheelie and kerbs using video feedback. Middle Range Theories: Five MRTs were developed through the synthesis of multiple, interrelated CMOcs, reflecting the complex and dynamic nature of MWC training. Rather than following a single, linear logic chain, these theories recognize that multiple mechanisms can be activated in a particular context, and that the outcomes are often shaped by a constellation of interacting mechanisms working together. Four of the MRTs were developed from a combination of literature and interview data and one from interview data alone (MRT 4). Self-Determination theory (31) helped explain the basis of multiple MRTs (MRT 1,2,4 and 5), as well as Social Cognitive Theory (36) (MRT 1, 3, 4 and 5), Cognitive load theory (35) (MRT 1, 2, 3), Social Learning Theory (34) (MRT 5) and Situated Learning Theory (32) (MRT 3). The five MRTs will be presented using the following headings; Resources and Training, Safe and Realistic environments, Peer and Social Support, Social Attitudes, Person Centred/Goal Driven Training. The MRTs and their alignment to relevant learning/rehabilitation theory are depicted in Table 4 as if-then-because statements to clearly articulate the causal logic underpinning each theory. Table 4 Middle Range Theories presented as if-then-because statements alongside relevant learning and rehabilitation theories. Middle Range Theory If-then-because statement Associated learning or rehabilitation theory Resources and training If manual wheelchair training is supported by adequate healthcare resources, including access to appropriate equipment and skilled trainers, then users are more likely to receive suitable wheelchairs and effective training, because well-resourced services enable personalised support that builds confidence through mastery experiences, which promotes skill development, supports safe use, and facilitates community participation. Social Cognitive theory, Self-determination theory, Cognitive load theory Person centred/goal driven trainings If manual wheelchair training is collaboratively tailored to an individual’s needs and goals rather than using a one-size-fits-all approach, then users experience increased empowerment and motivation, because personalised training fosters a sense of ownership and relevance, leading to greater satisfaction, improved confidence, and more effective achievement of wheelchair use goals. Self-determination theory, Cognitive load theory Safe and authentic environments If manual wheelchair training is delivered in environments that balance physical safety with real-world relevance, then users are more likely to develop confidence and self-efficacy in their wheelchair use, because practicing in settings that feel both safe and contextually meaningful supports psychological readiness, skill generalisation, and community participation. Situated learning theory, Social cognitive theory, Cognitive load theory. Social attitudes If wheelchair trainers, family, and friends perceive manual wheelchair (MWC) training as a pathway to independence, then users are more motivated, develop greater acceptance of MWC use, and demonstrate improved skill acquisition and wheelchair use, because positive expectations and encouragement from significant others enhance motivation and reinforce the value of skill development. Self-determination theory, Social cognitive theory Peer and social support If manual wheelchair training incorporates trusted social supports, such as peer mentors, fellow wheelchair users, and family or caregivers, then users are more likely to experience psychological safety, increased motivation, and stronger self-efficacy, because trusted relationships foster emotional support, relatable role modelling, and shared learning, which together build confidence, independence, and acceptance of wheelchair use. Self-determination theory Social learning Theory Social cognitive theory MRT 1: Resources and Training When MWC training is limited by healthcare resource constraints, users often receive unsuitable wheelchairs and inadequate training on wheelchair use. This undermines their confidence and- hampers skill development which restricts community participation and increases the risk of injury. I was just literally given the chair and said “Go for your life”. (Michelle- MWC user) Reiterating the importance of resources, MWC trainers emphasised that appropriate equipment is needed for training to be effective. “ So if you don't have the right equipment, or you've got a clunky old wheelchair, there's only so much that anyone can do. So having a wheelchair that's a good fit and set up efficiently, I think, helps promote wheelchair skills, because otherwise it makes it too hard, and then people can't do it.” (Kristen- MWC Trainer) In contexts where individuals had access to MWCs that were prescribed, fitted and set up for their needs, the risk of injury is reduced, and users experience greater confidence, improved wheelchair skills and increased MWC use (12, 37–41). These outcomes are likely linked to enhanced physical stability and control afforded by well-matched equipment. MWC users and trainers also identified resource constraints and funding limitations reduced the scope and quality of training provided. This was particularly noted in acute settings where time, staffing and environmental limitations impact on training offered. Pheobe, a MWC trainer reflected on this; “I think ideally we should be teaching people how to go up and down curbs and how to manoeuvre a wheelchair on uneven terrain outside, or if there's a camber on the footpath, I can pretty confidently say we don't ever do that in the acute setting.” (Pheobe- MWC trainer) Resource constraints lead to user’s having limited MWC skills and decreased confidence in MWC use, negatively impacting on community participation and engagement and increasing a users’ injury risk. “It got to the stage that I didn't feel safe, and I didn't feel comfortable [in the MWC]. So I then, you know, forced myself, when I went out in the public to use my walking sticks. So that puts me at an increased risk of falls.” (Chris- MWC user) In addition to resource constraints, MWC trainers highlighted a lack of guidance on training design and service delivery. In the absence of clear guidance, trainers relied heavily on personal experience, leading to inconsistent training quality. MWC users identified this led to suboptimal outcomes, including increased injury risk and user dependency for community participation. MWC Trainers expressed a need for structured guidance to support consistent practice. As Francesca, a MWC user noted; “I think something like a simple form … it should be almost ticked off regularly, rather than just being the informal training which may vary depending who's teaching it” (Francesca- MWC Trainer) Structured programs and clinical guidelines for MWC training provide a supportive framework that enhances trainer confidence, promotes consistent instruction, and improves skill acquisition and propulsion technique among users (3, 4, 40, 42). MRT 2: Person Centred and Goal Driven Training When MWC training is collaboratively tailored to individual needs and goals it empowers and motivates users, leading to greater satisfaction with training, improved confidence and more effective wheelchair related goal achievement (12, 37, 42–53). Trainers noted that when training was meaningful and relevant, users were more engaged in training. “I think one of the things that works there is making the task functional. If they want to go to the shop, if you can tie it in.” (Francesca- MWC trainer) Taking a scaffolded approach to skill development, where task complexity is adjusted to match a users’ capacity, is especially important for MWC users with chronic or progressive conditions (10, 12, 47, 54–57). This approach supports management of cognitive load, reduces overwhelm, and fosters control and empowerment (35). Trainers noted that having a clear goal pathway increases motivation and engagement in training. “You know, you wanna get there. You might not be able to do that yet, because that involves going up a step, and you haven't got that yet. But if you can work on this and then this, and then this, you can get to that point.” (Vince- MWC Trainer) Additionally, planning training that is self-paced and tailored to individual learning preferences enhances confidence, motivation and engagement (58). Trainers highlighted the Importance of adapting communication and teaching strategies to the user’s cognitive abilities and health literacy needs. “Some of the older population, generally sort of like seventies and above, or if they have lower levels of health literacy, you can kind of talk till the cows come home. But you can just tell that they're not understanding what you mean.” (Pheobe-MWC Trainer) Incorporating real time and retrospective visual feedback, such as video review or propulsion metrics also supports users’ understanding and engagement (59). These tools help users to see their propulsion technique, encourage self-reflection and promote active involvement in their training, leading to improved consistency and efficiency with wheelchair propulsion (60–64). MRT 3: Safe and authentic environments When MWC training is delivered in environments that balance physical safety with contextual relevance, MWC users are more likely to develop confidence and self-efficacy leading to increased community MWC use. MWC skills and independence are supported when training occurs in predictable, low risk environments (12, 42, 43, 65). Such settings minimise injury and anxiety, while fostering self-efficacy. Gradually increasing environmental demands supports skill attainment and confidence, making users more likely to persist through challenges. MWC users and trainers recognised the value of starting in controlled, indoor environments before transitioning to less predictable outdoor settings. “We've got a 10 centimeter platform step and we've got obstacles that we can put up to learn the basics like caster flicks in ascending and descending a step……… I find teaching those skills in a closed environment much easier [to complete first] before transitioning to the community.” (MWC Trainer-Laura) Wheelchair simulators (66) offer another way to introduce environmental complexity in a safe, controlled manner (4, 61). Simulation based training can enhance engagement and confidence while supporting skill transfer across varied settings through repeated, low risk practice. However, while safe environments were identified as being important, both MWC users and trainers emphasised that a sense of safety alone was not sufficient to ensure effective learning and long-term independence. Frank, a MWC user reflected; “The initial training in a hospital if you are just in a safe environment. You're only ever gonna expect it to be safe. And life's not like that.” (Frank- MWC user) Participants emphasised the importance of training in environments that reflect everyday settings and challenges MWC users are likely to encounter. One MWC trainer illustrated this idea; “It [training in environments the MWC will be used in] helps them [MWC users] to see what kind of challenges they might have, because often they'll say, Oh, I'll be fine. I'll be able to do that. But actually, when they go to do it, there's all these barriers that they haven't thought about.” (MWC Trainer- Bianca) Multiple papers incorporated training in community settings, such as shops and public gardens, recognising that practicing in familiar, meaningful environments boosts confidence and enhances satisfaction with training, leading to increased wheelchair use and community participation, which positively influences quality of life, (44, 48, 57, 67, 68). Without this training, users may rely upon trial-and-error style learning, increasing their risk of adverse events (12). MWC users also reported that limited community -based training reduced their confidence to access the community, increasing dependence on caregivers, which is particularly problematic when care partners were not included in the training process. MRT 4: Social Attitudes When individuals face mobility loss that necessitates starting MWC use, they can internalize societal attitudes that value walking as a symbol of independence. In this context the wheelchair can be seen as a symbol of disability, triggering feelings of shame, reluctance or pessimism towards wheelchair use. “Part of that emotional journey is the shame that you feel, the embarrassment that you feel to start off with.” (Chris- MWC user) This challenge is often compounded by the attitudes of some healthcare professionals and trainers in hospital settings, who may prioritize mobility-related outcomes such as walking over wheelchair training. As a result, engagement in MWC training is low and can limit a MWC users’ adjustment and effective MWC use. Cultural expectations and stereotypes, particularly about what older MWC users are capable of, can also undermine confidence and willingness to engage in training (12). These stereotypes often portray older adults as frail, dependent, or less able to learn new skills, which can lead to users and trainers having lowered expectations for training outcomes. Such assumptions may create psychological barriers that result in fewer opportunities for skill development, hindering meaningful participation in wheelchair use. When wheelchair trainers, family and friends view MWC training as a crucial step towards a user gaining independence in everyday living and community engagement, their positive attitudes and encouragement influence the users’ motivation and acceptance of wheelchair use. This helps the user engage more fully in training, leading to improved skill acquisition and greater confidence in using the wheelchair. This was reflected by Francesca, MWC trainer; “Family and friends relationships make a big difference. If family and friends are very positive about wheelchair use, then that patient is more motivated.” (Francesca- MWC trainer) MRT 5: Peer and Social Support MWC users experience greater psychological safety, motivation and self-efficacy when training incorporates trusted social supports, such as peer mentors, peer wheelchair users and family or caregivers. These mechanisms enhance confidence, foster independence and support greater acceptance of wheelchair use. The presence of caregivers during training provided emotional reassurance and practical encouragement, enabling users to feel safer and more willing to attempt new skills (48, 68). “We don’t do it that much , [incorporate caregivers into training] but you know, it would make them feel more comfortable if they've got a family member there.” (Libby- MWC trainer) Group and peer led training models are associated with improved engagement (54), greater confidence in wheelchair skills and increased participation in activities of daily living (42, 43, 69). MWC users and trainers noted that shared lived experiences triggered mechanisms such as camaraderie, belonging and psychological safety, enhancing the training experience (12, 48). This finding was highlighted by Hannah, a MWC trainer; “A sense of safe space connectedness to other people and feeling supported by each other, learning together all those lovely things that come with a group dynamic.” (Hannah- MWC trainer) Group training introduces fun and social interaction into the learning process, making training feel less clinical and more engaging. This atmosphere increases MWC users’ motivation and willingness to participate (12, 52) and allows for social learning (34), where individuals acquire new skills by watching others. Additionally, witnessing peers succeed serves as a powerful source of vicarious motivation (36), boosting users’ confidence and belief in their own ability to improve. “One of the things that's really vital is having trainers who are wheelchair users themselves…. you have so much cultural capital going into the room.” (Vince-MWC trainer) When MWC users are trained by peers with lived experience or watch videos of skills being performed, they are not only shown how to perform wheelchair skills but are also offered insight into what is possible. This supports user confidence, positively impacting on skill acquisition (12, 39, 45–47, 56, 61, 70–73). Modelling often offers reassurance that goals are achievable and provides a clear understanding of what is expected, helping to reduce anxiety and support self-efficacy. “Having someone show you is important….when you're actually sitting in a chair, it's a different kettle of fish.” (Michelle- MWC user) Group-based training also provides opportunity to observe, compare and reflect on different approaches to wheelchair use, helping MWC users to refine their own techniques. This shared learning environment can lead to improved skill acquisition and greater confidence in MWC use. However, in some cases users reported reduced confidence when there was a large skill disparity between themselves and others, which triggered lower self-efficacy (49). Links to established theory These MRTs align with established learning and rehabilitation theories, which explain how and why the proposed mechanisms may work. When MWC training is supported by adequate health resources (MRT1 ) and collaboratively tailored to an individuals’ needs and goals (MRT 2), the mechanisms that lead to increased skill acquisition and wheelchair use can be supported by self-determination theory (31), whereby access to personalised training allows choice over training, supports training ownership and fosters a sense of competence, leading to increased motivation to enhance skill development. Access to trained staff and appropriate equipment also creates opportunities for successful experiences and modelling, which strengthens self-efficacy, positively influencing skill acquisition (social cognitive theory (36)). Additionally, having well-resourced training which is aligned to the users’ needs means that training can be catered to the right level of challenge enabling more efficient learning and wheelchair use (cognitive load theory (35)). A graduated increase in the environmental complexity of training as outlined in MRT 3, scaffolds cognitive load related to new skill learning. More structured training environments reduce extrinsic cognitive load, permitting more efficiency in learning new skills, with transfer to more complex environments permitting the development of schematic complexity (cognitive load theory(35)). At the same time, practicing in meaningful settings strengthens learning by enabling users to perform everyday tasks, receive feedback and build self-efficacy though successful experiences (social cognitive theory (36), situated learning theory (32)). Embedding training in environments that reflect users’ daily contexts not only supports motivation and confidence but also promotes skill generalisation and sustained engagement. When wheelchair peers and care partners are incorporated into MWC training (MRT 5) and when trainers, family and peers hold positive attitudes towards MWC training (MRT 4) the resulting psychological safety and social reinforcement enhance skill acquisition and community participation. These outcomes are supported by Social Learning Theory (34), where learning is shaped through observation and modelling, and by Social Cognitive Theory (36), which highlights the role of self-efficacy, developed through social encouragement and vicarious experiences. Additionally, self-determination theory (31) explains how environments that foster autonomy, relatedness and competence, such as those that integrate trusted social supports, promote intrinsic motivation and engagement in training. Discussion This research presents the outcomes of a realist synthesis designed to explain how and why manual wheelchair training works for individuals who commence wheelchair use due to chronic or progressive conditions. Drawing on literature and qualitative interviews with MWC users and trainers and guided by existing rehabilitation and learning theories, five MRTs were developed. These MRTs offer generalisable causal explanations of the mechanisms through which MWC training leads to positive outcomes. Collectively they reflect the importance of a well -resourced, user-centred, socially supportive and contextually relevant approach to MWC training. Access to well fitted equipment, trained personnel and dedicated training time is critical to developing MWC users’ confidence and proficiency (MRT 1). However, this research highlights persistent challenges in accessing MWC training for individuals with chronic and progressive conditions. Current funding structures are heavily weighted towards hospital-based services (74), where younger individuals with traumatic injuries are more likely to receive well-resourced training support. In contrast, those with chronic or progressive conditions often acquire a wheelchair through community pathways or are transitioned more rapidly out of hospital care without structured training, reflecting a system poorly aligned with the needs of people with gradual functional decline. These inequities are shaped by institutional ageism (75), where service pathways and funding models tend to prioritise younger populations, while undervaluing the mobility needs of older adults (76, 77). In response to calls for greater consumer choice and control, health and disability systems are increasingly adopting individualized funding models that allow users to decide which services best meet their needs. However, these models also present challenges. Consumers often face complex navigation processes, leading to long delays in accessing and using allocated funds (78, 79) and can encounter limited availability of skilled service providers (79). As a result, individuals may be unable to access MWC training at the time they are in most need of it ie., during initial adjustment to wheelchair use or upon reintegration to the community. This reduces the potential impact of training on confidence, independence and community participation. Fragmentation across healthcare systems further impedes access to MWC training (80, 81). Acute, subacute and community services frequently operate in silos with limited communication and different priorities, leading to poorly coordinated care pathways. Inconsistent referral pathways contribute to missed opportunities for follow up training after hospital discharge. Hospital systems typically prioritise discharge efficiency and short-term functional outcomes, resulting in training that is either skill focused or omitted entirely (8, 9, 11, 81–83). This limits the potential for training to be individualised, meaningful and goal directed, factors that are essential for supporting engagement (MRT 2). Hospital based training, while providing a controlled and safe environment for learning, offers limited opportunities for MWC users to practice wheelchair use in lived environments. As described in MRT 3, learning in authentic environments promotes confidence, skill generalisation and participation in daily life. Community based training, when available can support the easier integration of trusted social supports and caregivers into training, improving psychological safety and motivation. However, biomedical models dominate acute care, often overlooking factors that support psychosocial readiness including the lack of family inclusion within training. As emphasised in MRT 4, inclusive environments and positive social attitudes are essential for motivation and sustained participation. Without seamless transitions and cross sector communication, training will remain fragmented and unresponsive to users’ lived realities. There is also limited governance and accountability for training standards. Professional organisations, including the International Society of Wheelchair Professionals (ISWP) and the WHO have developed certification tools (ie., ISWP Trainer certification (84)), frameworks (ie., WHO’s Eight Steps for Appropriate Wheelchair Provision (85)), guidelines (ie., WHO’s wheelchair provision guidelines (15), Paralyzed Veterans of America’s Clinical Practice Guideline for Preservation of Upper Limb Function Following a Spinal Cord Injury (14)) training programs (ie., WHO’s Basic and Intermediate Training Packages (86, 87)) and resources (ie., ISWP Wheelchair educators package (88)) to strengthen wheelchair service capacity globally. Additionally, the Wheelchair Skills Program (16) is a freely available evidence-based training package that strives to promote consistency and quality assurance in wheelchair training delivery. However, while these initiative demonstrate growing international commitment, there is currently no designated body responsible for governance or oversight to ensure MWC training is delivered consistently, equitably and to an acceptable standard (89). Additionally, most of these resources provide general content guidance on skill development or biomechanical propulsion principles that are broadly applicable, yet they lack detailed strategies for tailoring training to diverse user needs or adapting it to the varied contexts in which training occurs. This gap is particularly important given the findings of MRT 2, which highlights the need for goal directed, individualised training, particularly for individuals adjusting to functional change due to chronic or progressive conditions. Without protocols that facilitate training that is responsive to the needs and contexts of the individual, such as flexible service models, scaffolded learning and individual goal setting, training risks becoming generic, disengaging or misaligned with the users’ needs. Without defined service expectations, mechanisms to monitor training outcomes, or structured feedback and follow up processes, basic practice is not consistently upheld, and training quality remains variable. Embedding accountability within service agreements, across sectoral and service systems and using national guidelines and funding frameworks is essential to ensure training is delivered as a core component of care. This includes implementing provider responsibilities, performance indicators, and reporting systems to support quality assurance and drive improvement across the care continuum. Inclusive training environments also require attention, particularly given their importance in fostering user motivation and participation (MRT 4). A major challenge in delivering this is the current shortage of individuals trained in the delivery of inclusive MWC training. Initiatives such as the ISWP trainer certification represents important progress towards building a competent workforce, however their impact is limited due to voluntary uptake, cost barriers and lack of integration into local systems (89). Existing training also often prioritizes biomedical approaches ie. focuses on physical and technical aspects of wheelchair use, with less emphasis on psychosocial and environmental dimensions that are equally critical to the user. To address these gaps, it is essential to broaden the scope of training to include more affirming and inclusive models. Peer-led models may offer such affirming approaches (43, 48, 51–54), as peer mentors provide emotional and practical support (90–93), reinforce self-efficacy, and model positive wheelchair use, which is central to developing proficiency in wheelchair use (MRT 5)(90–93).Strengthening workforce capabilities will require broader system level investment, including the upskilling assistive technology providers (6) and embedding MWC training more prominently within professional education programs (94, 95). Regardless of who is delivers training, all approaches must reflect inclusive and motivational practices that promote psychosocial wellbeing alongside skill development. Recommendations and Implications for Practice Collectively, the MRTs developed in this research reinforce prior calls (81) for equity in wheelchair training. System-wide reforms are needed to ensure consistent access to equipment and training regardless of age, diagnosis or funding stream. Integrated funding models and coordinated care pathways across hospital, community, health, disability and aged care services are essential to support user-centred, goal directed training. Governance structures should include guidance for best practice training delivery and investment in workforce development. Strengthening accountability through outcome monitoring, referral expectations and cross sector coordination is critical. Seven key recommendations that operationalise these priorities are summarised in Table 5 . Their implementation would support equitable, responsive and effective MWC training for individuals with chronic and progressive conditions. Implementation of these recommendations must be accompanied by research that evaluates user outcomes, training effectiveness, and system-level impact. Table 5 Summary of key recommendations Key Recommendation Strategies Equitable access to MWC training resources across care sectors • Address funding disparities between hospital and community-based services to ensure equitable access to training and equipment. • Redesign funding models to better support people with chronic or progressive conditions who acquire wheelchairs outside of hospital settings Integrate services across healthcare sectors • Improve coordination between acute, subacute and community settings to support seamless care transitions. • Develop consistent referral pathways to ensure access to follow up MWC training in the community MWC training is delivered in authentic and contextually relevant environments • Training to transition from safe, controlled environments to lived environments to support skill generalisation, confidence and participation. Training environments must be psychologically safe and inclusive • Integrate peer mentors, care partners and trusted social supports into MWC training. • Train staff to deliver inclusive, affirming care that recognises psychosocial and environmental influences. Provision of flexible, person-centred training delivery. • Create flexible service models that that emphasise individualised training approaches. • Provide practical tools and frameworks to support training personalisation of MWC training and alignment with user goals. Build workforce Capacity • Develop workforce strategies to ensure sufficient and skilled personnel to deliver MWC training across settings. • Incorporate MWC training into professional education programs and promote skill development for clinicians and assistive technology providers. • Invest in peer-led models of training. Embed accountability mechanisms for MWC training • Introduce system level accountability frameworks that define expectations for MWC training delivery. • Include outcome performance indicators and service level reporting • Clarify roles and responsibilities across sectors to ensure no aspects of MWC training are overlooked. Strengths and Limitations This research used a realist methodology to explore how and why MWC training interventions work, for who and under what conditions. Triangulation of systematic review data with stakeholder interviews, enhanced rigour and ensured findings were grounded in both evidence and lived experiences, to support the development of practical, theory-informed recommendations. Given interviews were completed with a small, Australian based sample only, the cultural and service generalisability of these findings may be limited. Additionally, the service assumptions and funding structures reflected in the discussion section of this research and subsequent recommendations are most applicable to middle and high-income contexts with established healthcare and rehabilitation systems. Further research is needed to explore how these findings might be adapted or applied in low resource settings. Conclusion This research developed five MRTs that explain how and why MWC training interventions work for individuals who commence MWC use later in life due to chronic and progressive conditions. Findings emphasise the need for system level reforms to ensure training is person centred, contextually relevant and equitably delivered. Addressing gaps in funding, governance, workforce and accountability is essential to embed training as a core component of care. Abbreviations ABI Acquired Brain Injury AHA Allied Health Assistant CMOc Context-Mechanism-Outcome configuration EP Exercise Physiologist IPT Initial Program Theory MWC Manual Wheelchair MRT Middle Range Theory MS Multiple Sclerosis NSW New South Wales OT Occupational Therapist RCT Randomized Control Trial SCI Spinal Cord Injury UK United Kingdom Declarations Ethics approval and consent to participate This research was conducted in accordance with the Declaration of Helsinki. Ethical approval for this study was obtained from the University of Adelaide Human Research Ethics Committee, approval number. H-2022-218. All participants provided informed consent prior to participation. Consent for publication Not Applicable Availability of data and material The datasets generated and/or analysed during this research are available from the corresponding author on reasonable request Competing interests The authors declare that they have no competing interests Funding There was no funding received for this research Authors Contributions All authors were responsible for conceptualization; methodology; writing—review & editing of this manuscript, KC was responsible for writing the original manuscript and for formal analysis and preparing all figures and tables. All authors contributed to interpretation of both datasets and SA, NL and CM were responsible for supervision. All authors have read and approved the final manuscript Acknowledgements Not applicable References Tu CJ, Liu L, Wang W, Du HP, Wang YM, Xu YB, et al. Effectiveness and safety of wheelchair skills training program in improving the wheelchair skills capacity: a systematic review. 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Peer-led wheelchair training improves wheelchair use self-efficacy and wheelchair skills: A pilot randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2016;97(10):e28. Desai R, Jayavant S, Varshneya H. To investigate the immediate and short term effects of wheelchair skill training program (WSTP) on participation in patients with spinal cord involvement. Indian Journal of Occupational Therapy (Indian Journal of Occupational Therapy). 2013;45(2):9-14. Kirby RL, Lugar JA, Breckenridge C. New wheelie aid for wheelchairs: controlled trial of safety and efficacy. Archives of Physical Medicine & Rehabilitation. 2001;82(3):380-90. Ozturk A, Ucsular FD. Effectiveness of a wheelchair skills training programme for community-living users of manual wheelchairs in Turkey: a randomized controlled trial. Clinical Rehabilitation. 2011;25(5):416-24. Kirby RL, Smith C, Miller MD, Osmond D, Sherman MA, Parker K, et al. Wheelchair skills training for caregivers of manual wheelchair users: a randomized controlled trial comparing self-study and remote training. Disability and Rehabilitation: Assistive Technology. 2024;19(8):2896 Limroongreungrat W, Chang L-S, Wang YT, Acker C, Maurer C, Sprigle S. Effectiveness Of Immediate Video Feedback On Wheelchair Propulsion Training For Patients With Spinal Cord Injuries: 2693 Board #87 May 29 3:30 PM - 5:00 PM. Medicine and science in sports and exercise. 2009;41(5):430. Blouin M, Lalumière M, Gagnon DH, Chénier F, Aissaoui R. Characterization of the immediate effect of a training session on a manual wheelchair simulator with haptic biofeedback: towards more effective propulsion. IEEE Trans Neural Syst Rehabil Eng. 2015;23(1):104-15. DeGroot KK, Hollingsworth HH, Morgan KA, Morris CL, Gray DB. The influence of verbal training and visual feedback on manual wheelchair propulsion. Disabil Rehabil Assist Technol. 2009;4(2):86-94. Rice I, Gagnon D, Gallagher J, Boninger M. Hand rim wheelchair propulsion training using biomechanical real-time visual feedback based on motor learning theory principles. Journal of Spinal Cord Medicine. 2010;33(1):33-42. Rice LA, Smith I, Kelleher AR, Greenwald K, Hoelmer C, Boninger ML. Impact of the clinical practice guideline for preservation of upper limb function on transfer skills of persons with acute spinal cord injury. Archives of Physical Medicine & Rehabilitation. 2013;94(7):1230-46. Richter WM, Kwarciak AM, Guo L, Turner JT. Effects of single-variable biofeedback on wheelchair handrim biomechanics. Arch Phys Med Rehabil. 2011;92(4):572-7. Choi WS, Lee JM, Kim TY, Kim JH, Lee JA, Choi H. Development of Adjustable Wheelchair Training Structure and Validation of Usefulness for Evaluation and Training of Manual Wheelchair Skill. Journal of Mechanics in Medicine and Biology. 2020;20(10). Chaar F, Archambault PS. Usability of a virtual reality manual wheelchair simulator. Disability & Rehabilitation Assistive Technology. 2022:1-11. Best KL, Kirby RL, Smith C, MacLeod DA. Wheelchair skills training for community-based manual wheelchair users: a randomized controlled trial. Archives of Physical Medicine & Rehabilitation. 2005;86(12):2316-23. Kirby RL, Mitchell D, Sabharwal S, McCranie M, Nelson AL. Manual Wheelchair Skills Training for Community-Dwelling Veterans with Spinal Cord Injury: A Randomized Controlled Trial. PLoS ONE [Electronic Resource]. 2016;11(12):e0168330. Worobey LA, Kirby RL, Heinemann AW, Krobot EA, Dyson-Hudson TA, Cowan RE, et al. Effectiveness of Group Wheelchair Skills Training for People With Spinal Cord Injury: A Randomized Controlled Trial. Archives of Physical Medicine & Rehabilitation. 2016;97(10):1777-84.e3. Bonaparte JP, Kirby RL, Macleod DA. Learning to perform wheelchair wheelies: comparison of 2 training strategies. Archives of Physical Medicine & Rehabilitation. 2004;85(5):785-93. Yong Tai W, Limroongreungrat W, Li-Shan C, Xiang K, Liang-Ching T, Yu-Ping C, et al. Immediate video feedback on ramp, wheelie, and curb wheelchair skill training for persons with spinal cord injury. Journal of Rehabilitation Research & Development. 2015;52(4):421-30. McClure LA. Implementation of clinical practice guidelines following acute spinal cord injury: University of Pittsburgh; 2010. Rice IM, Pohlig RT, Gallagher JD, Boninger ML. Handrim wheelchair propulsion training effect on overground propulsion using biomechanical real-time visual feedback. Arch Phys Med Rehabil. 2013;94(2):256-63. Health AIo, Welfare. Health expenditure. Canberra: AIHW; 2024. Nuessel FH, Jr. The Language of Ageism. The Gerontologist. 1982;22(3):273-6. Saif-Ur-Rahman KM, Mamun R, Eriksson E, He Y, Hirakawa Y. Discrimination against the elderly in health-care services: a systematic review. Psychogeriatrics. 2021;21(3):418-29. Lloyd-Sherlock PG, Ebrahim S, McKee M, Prince MJ. Institutional ageism in global health policy. BMJ. 2016;354:i4514. Fleming P, McGilloway S, Hernon M, Furlong M, O'Doherty S, Keogh F, et al. Individualized funding interventions to improve health and social care outcomes for people with a disability: A mixed-methods systematic review. Campbell Syst Rev. 2019;15(1-2):e1008. Fleming P, McGilloway S, Barry S. The successes and challenges of implementing individualised funding and supports for disabled people: an Irish perspective. Disability & Society. 2016;31(10):1369-84. Stange KC. The Problem of Fragmentation and the Need for Integrative Solutions. The Annals of Family Medicine. 2009;7(2):100. Gowran RJ, Clifford A, Gallagher A, McKee J, O'Regan B, McKay EA. Wheelchair and seating assistive technology provision: a gateway to freedom. Disability & Rehabilitation. 2022;44(3):370-81. Kirby RL, Keeler L, Wang S, Thompson K, Theriault C. Proportion of Wheelchair Users Who Receive Wheelchair Skills Training During an Admission to a Canadian Rehabilitation Center. Topics in Geriatric Rehabilitation. 2015;31(1):58-66. Hoenig H, Griffiths P, Ganesh S, Caves K, Harris F. The accuracy of new wheelchair users' predictions about their future wheelchair use. Am J Phys Med Rehabil. 2012;91(6):511-8. ISWP. Wheelchair Trainer Certification University of Pittsburgh: ISWP; 2024 [Available from: https://iswp.org/wheelchair-trainer-certification/. WHO. Wheelchair Service Training of Trainers Package: ToT Handbook Basic Level Geneva, Switzerland 2017. WHO. Wheelchair Service Training Package- Reference Manual for Participants Basic Level Generva, Switzerland 2012. WHO. Wheelchair Service raining Package: Participants workbook Intermediate Level Geneva, Switzerland 2013. ISWP. Wheelchair Educators Package Pittsburgh: ISWP; 2024 [Available from: https://wep.iswp.org/. Goldberg M, Rushton P, Kirby RL, Muñera S, Kandavel K, Pearlman J, et al. Wheelchair service provision content in professional rehabilitation organisations' standards documents and contemporary initiatives: a rapid review. Disabil Rehabil Assist Technol. 2022:1-12. Veith EM, Sherman JE, Pellino TA, Yasui NY. Qualitative analysis of the peer-mentoring relationship among individuals with spinal cord injury. Rehabilitation Psychology. 2006;51(4):289. Gassaway J, Jones ML, Sweatman WM, Hong M, Anziano P, DeVault K. Effects of Peer Mentoring on Self-Efficacy and Hospital Readmission After Inpatient Rehabilitation of Individuals With Spinal Cord Injury: A Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation. 2017;98(8):1526-34.e2. Barclay L, Hilton GM. A scoping review of peer-led interventions following spinal cord injury. Spinal Cord. 2019;57(8):626-35. Thompson DM, Booth L, Moore D, Mathers J. Peer support for people with chronic conditions: a systematic review of reviews. BMC Health Services Research. 2022;22(1):427. Burrola-Mendez Y, Kamalakannan S, Rushton PW, Bouziane SA, Giesbrecht E, Kirby RL, et al. Wheelchair service provision education for healthcare professional students, healthcare personnel and educators across low- to high-resourced settings: a scoping review. Disability & Rehabilitation Assistive Technology. 2022:1-22. Fung K, Miller T, Rushton PW, Goldberg M, Toro ML, Seymour N, et al. Integration of wheelchair service provision education: current situation, facilitators and barriers for academic rehabilitation programs worldwide. Disabil Rehabil Assist Technol. 2020;15(5):553-6 Additional Declarations No competing interests reported. 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Charlton","email":"data:image/png;base64,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","orcid":"","institution":"University of Adelaide","correspondingAuthor":true,"prefix":"","firstName":"Kimberly","middleName":"","lastName":"Charlton","suffix":""},{"id":513216666,"identity":"cf20d4e6-cd19-4061-bbd4-c74683c48e1f","order_by":1,"name":"Carolyn Murray","email":"","orcid":"","institution":"University of South 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22:53:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7483544/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7483544/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-025-13727-0","type":"published","date":"2025-12-29T15:57:36+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":91357359,"identity":"27b667bb-b7ee-46a6-8395-a4d3d82d8064","added_by":"auto","created_at":"2025-09-15 15:41:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":102359,"visible":true,"origin":"","legend":"\u003cp\u003eProcess for Program Theory Development\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7483544/v1/59b83eb23858dcc8caa92de3.png"},{"id":91357788,"identity":"f0315b36-376b-4be1-803c-9f1a6341c9c9","added_by":"auto","created_at":"2025-09-15 15:49:34","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":192663,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7483544/v1/7797f96bb6a66fb1c8dce524.png"},{"id":91357789,"identity":"3b3f3d89-89fd-490f-bbb1-354a7fd27855","added_by":"auto","created_at":"2025-09-15 15:49:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":226665,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration of the refinement of Early Program Theories to Initial Program Theories to Middle Range Theories.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7483544/v1/5093c3d57d423c36132c62c2.png"},{"id":99545264,"identity":"035737bb-4daf-449a-b989-420c00bf621a","added_by":"auto","created_at":"2026-01-05 16:04:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2101472,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7483544/v1/653ca9d3-9030-458c-9bc0-7752f3426151.pdf"},{"id":91357358,"identity":"296c1b37-8445-4acd-a875-13d4e01896c4","added_by":"auto","created_at":"2025-09-15 15:41:34","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":23837,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7483544/v1/7573ceb7f9a71c80366831cb.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Manual wheelchair training for individuals with chronic and progressive conditions: A critical realist approach to improving practice","fulltext":[{"header":"Background","content":"\u003cp\u003eManual wheelchair (MWC) training plays a critical role in promoting safe, confident and efficient wheelchair use. When delivered effectively, training can improve mobility and confidence, support independence and enable participation in meaningful activities, ultimately enhancing quality of life (1, 2). It helps reduce the risk of upper limb injuries related to overuse or incorrect propulsion, as well as falls (3\u0026ndash;5). Training also lessens caregiver burden and reduces reliance on healthcare services, leading to broader social and economic benefits.\u003c/p\u003e\u003cp\u003eDespite these benefits, access to MWC training is often limited to certain populations, such as individuals with spinal cord injury. Those who begin using a wheelchair part- or full-time due to gradual functional decline associated with chronic or progressing conditions, are frequently excluded from training opportunities (6) or receive training that is inconsistent, brief (7\u0026ndash;11) and may not always meet the needs or desired outcomes of users (12). Several systematic barriers contribute to this problem, including an inadequate number of appropriately trained personnel (13), competing priorities of the MWC trainer workforce (6\u0026ndash;9, 11), wheelchair service providers operating in silos without established referral networks and links between providers (6), short inpatient rehabilitation stays and a lack of funding and resources for quality MWC training provision (6\u0026ndash;9, 11).\u003c/p\u003e\u003cp\u003e Recommendations for MWC propulsion education (14) and general guidelines for wheelchair training exist (15) and aim to support positive training outcomes for all MWC users. However, these are often generic and not tailored to the diverse and evolving needs of all wheelchair users, including those with chronic or progressive conditions who may present with unique physical, cognitive and emotional challenges. They also offer limited guidance on adapting content to different contexts or user needs. Similarly, standardised, evidence-based training protocols exist (16) yet they frequently focus strongly on physical skill acquisition (17) and do not attend to emotional, cognitive and psychological needs of individuals with complex or progressive conditions nor do they provide practical detail on delivering person centred training in varied settings. This oversight is problematic as the potential positive outcomes of MWC training are not being fully realised (17), highlighting the need to improve and rethink how MWC training is delivered, particularly for people commencing MWC use due to chronic or progressive conditions.\u003c/p\u003e\u003cp\u003eA critical realist approach is one way to interrogate these challenges (18). Realist research is based on the premise that outcomes arise from underlying mechanisms, often which cannot be seen, and operate differently depending on the context (18). As such, interventions may work in one setting but not in another, depending on the contextual conditions and mechanisms they trigger. A realist synthesis applied this logic to systematically develop and refine program theories, which are evidence-informed explanations of how and why an intervention works, from whom and in what contexts (19). While a realist synthesis primarily draws upon literature to build these theories (19), it may also incorporate stakeholder interviews to test and refine theories and to ensure their relevance to practice (20). This iterative process strengthens the explanatory power and practical relevance of program theories by grounding them in both existing evidence and lived experience (21\u0026ndash;24).\u003c/p\u003e\u003cp\u003eProgramme theories are typically expressed as a Context-Mechanism-Outcome configuration (CMOc), a heuristic that prompts researchers to consider how specific contexts enable or constrain mechanisms to produce particular outcomes. The iterative development of program theories provide more transferrable, practice ready explanations of what works, for whom and in what circumstances (25).\u003c/p\u003e\u003cp\u003eGiven the complexity of MWC training delivery and the diversity of user needs, particularly among individuals with chronic or progressive conditions, a deeper understanding is needed of how, why and under what circumstances MWC training supports meaningful outcomes. This research uses a realist synthesis to develop and refine program theories that can inform more tailored and effective training approaches.\u003c/p\u003e\u003cp\u003eResearch question: What works, for whom, in what contexts and why, in manual wheelchair training for those commencing wheelchair use due to chronic or progressive conditions?\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eMethodological approach\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA critical realist approach was adopted for this research to explore of how, why and under what circumstances MWC training works by examining the interactions between contexts, mechanisms and outcomes \u0026nbsp;(19). \u0026nbsp; Early program theories were initially developed based on practice knowledge and clinical experience, then refined through a systematic review of literature to inform the development of initial program theories (IPTs) related to MWC training. These theories were further developed and refined through interviews with MWC users with chronic or progressive conditions and trainers who had experience working with this population. Insights from all sources enabled iterative shaping and testing of program theories, allowing for a more nuanced understanding of what works for whom and in what circumstances, specifically for individuals commencing wheelchair use due to a chronic or progressive condition. To further strength the explanatory power of these theories, relevant rehabilitation and learning theories were incorporated to guide the refinement of IPTs into middle range theories (MRTs). This theoretical grounding also informed the development of recommendations tailored to the needs of this population. \u0026nbsp;Figure 1 outlines the overarching process of program theory development. The RAMESES publication standards for realist syntheses were followed (26) in this research paper.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLiterature\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA systematic search strategy was conducted to identify papers on manual wheelchair training, first in July 2022 and updated in September 2023 and May 2025. Papers\u0026nbsp;solely focused on paediatric or abled bodies users simulating as wheelchair users, were excluded to enable literature to be nuanced to wheelchair training for adults/older adults.\u0026nbsp;This full search strategy has been published elsewhere (27).\u0026nbsp;\u0026nbsp;Ninety-seven papers were assessed for \u003cem\u003erelevance\u003c/em\u003e, i.e., could the paper add to the developing program theories? and \u003cem\u003erigor\u0026nbsp;\u003c/em\u003ei.e., was the method used to generate data plausible for answering the research question and were the findings well supported by data collected (19). \u0026nbsp; Table 1 details the inclusion and exclusion criteria. \u0026nbsp;Forty-eight papers met relevance and rigor requirements and were included for data extraction. Figure 2 illustrates the PRISMA flowchart for study selection. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1. inclusion and Exclusion criteria\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eInclusion Criteria\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eParticipant group:\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eManual Wheelchair users\u0026nbsp;and/or their caregivers who were commencing wheelchair use as adults\u003c/li\u003e\n \u003cli\u003ePapers where only some participants met the inclusion criteria (on the basis that they may have applicability to those commencing wheelchair use as adults\u003c/li\u003e\n \u003cli\u003ePapers which had a mix of powered and manual wheelchair users\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eIntervention/Concept:\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eWheelchair training program describing outcomes (must have sufficient detail to identify Contexts, Mechanisms and Outcomes to be able to contribute meaningfully to theory development).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMWC user, carer or trainer perspectives of manual wheelchair training where Contexts, Mechanisms and Outcomes of wheelchair training can be identified and have sufficient depth to contribute meaningfully to theory development. \u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003ePaper type:\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eArticles in English\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePublished after 1995\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eExclusion criteria\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eParticipant group:\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eAble-bodied persons simulating wheelchair users, including clinicians and students\u003c/li\u003e\n \u003cli\u003ePaediatric wheelchair users\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eIntervention/concept:\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eExclusive focus on exercise programs designed to strengthen muscles or improve fitness for \u0026nbsp;wheelchair use\u003c/li\u003e\n \u003cli\u003eExclusive training of powered wheelchair use \u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003ePaper Type:\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eAny reviews of literature ie., scoping reviews, systematic reviews, literature reviews, summary/position papers.\u003c/li\u003e\n \u003cli\u003eSurveys that are not specific to one wheelchair training program\u003c/li\u003e\n \u003cli\u003eWheelchair training protocols or any training programs where outcomes have not been measured\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePapers that do not provide sufficient information to identify at least two of the following; context, mechanism, outcome.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003eInterviews\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSix manual wheelchair users who commenced MWC use as an adult due to chronic, or progressive conditions, along with 11 trainers who delivered \u0026nbsp;MWC training to adults with a range of conditions, including neurological disorders, amputations, orthopaedic injuries and Spinal Cord Injury (SCI) completed individual semi-structured interviews online via Zoom (Zoom Video Communications Inc.) over an eleven-month period from January 2024 to November 2024. Trainers were included if their training experience extended beyond SCI and included individuals with chronic or progressive conditions, reflecting the study\u0026rsquo;s aim to explore perspectives underrepresented in the literature. Separate interview guides were developed for MWC trainers and users, designed to explore explanatory mechanisms for wheelchair training outcomes based on existing experience, literature and stakeholder perspectives (28). The interview guide used in this study was published previously (6) and was piloted with a MWC trainer and user known to the research team, was and refined based on feedback. \u0026nbsp;Interview guides continued to be iteratively refined throughout the data collection process to deepen the \u0026nbsp;exploration \u0026nbsp; of explanatory mechanisms (28). Full details on recruitment and data collection have been previously published (6).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData extraction\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData from qualitative interviews and research papers were extracted. \u0026nbsp;Demographic information from MWC user/trainers, along with study characteristics from research papers (i.e., author name, publication year, country of publication, types of paper, type of participants, intervention) were recorded. An excel spreadsheet template was used to extrapolate contextual factors, mechanisms and outcomes from both qualitative interviews and research papers. \u0026nbsp;\u0026nbsp;\u003cem\u003eContexts\u0026nbsp;\u003c/em\u003ewere identified by examining the methodologies of included papers and participant accounts \u0026nbsp; (29). \u0026nbsp; \u0026nbsp;To categorise the identified \u0026nbsp;contexts, the Environmental Factors chapters of the World Health Organisation\u0026rsquo;s International Classification of Functioning (ICF) were used.\u0026nbsp;This includes five key chapters; \u0026nbsp;\u0026nbsp;products and technology, natural environment and human made changes to the environment, support and relationships, attitudes and services, systems and policies.\u0026nbsp;This framework is widely recognised and provides a structured approach for categorising \u0026nbsp; environmental influences on human functioning,\u0026nbsp;making it well-suited to identify how different contextual elements may activate or constrain mechanisms.\u0026nbsp;\u003cem\u003eMechanisms,\u003c/em\u003e which are often unobservable, were inferred from participant\u0026rsquo;s explanations of why they believed change occurred, including emotional (i.e., motivation), cognitive (i.e., self-efficacy), or social responses \u0026nbsp;(i.e., peer encouragement) to training. In research papers, mechanisms were identified in authors\u0026rsquo; interpretations, discussion sections and descriptions of the intervention process that suggested why certain outcomes were observed in specific outcomes (20, 29). \u003cem\u003eOutcomes\u003c/em\u003e referred to the effects or changes resulting from the intervention\u0026nbsp;and were drawn from reported changes in outcomes as described in study results and as reflected on by participants during interviews.\u0026nbsp;\u0026nbsp;Outcomes included behavioural, psychological, functional or health related outcomes. Examples\u0026nbsp;of extracted data can be found in Table 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2. Examples of extracted under Contexts-Mechanisms-Outcomes\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.6406%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84.3594%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExamples\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.6406%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContext\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84.3594%;\"\u003e\n \u003cp\u003e\u003cu\u003eProducts and Technology\u003c/u\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eBiofeedback provided through technology, wheelchair simulators, tablet-based training, spotter straps, wheelchair set up, wheelchair anti tip bars.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u003cu\u003eServices, Systems and Policies\u003c/u\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eOrganisational/institutional factors of the health services implementing an intervention (ie., the follow through of training across healthcare settings)financial resources (ie., high resourced or low resources settings), regulations/policies or procedures influencing intervention delivery.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u003cu\u003eAttitudes\u003c/u\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eStereotypes, attitudes of trainers, peers and family.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u003cu\u003eSupport and Relationships\u003c/u\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eSocial environment in which an intervention takes place, including \u0026nbsp;peer led training, group training, presence of carers in training, inclusion of spotters and skills of the trainer.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u003cu\u003eNatural environment and human made changes to the environment\u003c/u\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003ePhysical environment in which an intervention takes place ie homes, community, hospitals, laboratories, online, simulated environments, training camps.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.6406%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMechanism\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84.3594%;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePsychological mechanisms: Ie., Increased confidence, improved self-efficacy, fear/anxiety reduction, motivation/level of engagement\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSocial mechanisms: Ie., peer, instructor or family/caregiver support\u003c/li\u003e\n \u003cli\u003eCognitive mechanisms: Ie., Increased learning/understanding, increased coping ability, increased ability to process feedback.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePhysical mechanisms: Ie., changes in muscle strength, coordination or endurance, neuroplastic changes.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.6406%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84.3594%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eIncreased propulsion efficiency, reduced pain,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eIncreased mobility, increased community and social participation, increased engagement in activities of daily living, increased independence, safety.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eStronger social supports/relationships, improved attitudes towards MWC use\u003c/li\u003e\n \u003cli\u003eIncreased confidence, Improved self-efficacy.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData obtained from the systematic search process and interviews were initially analysed separately. A retroductive analytical approach was used to develop context-mechanism-outcome configurations (30). This involved working backwards from observed outcomes to infer the underlying causal mechanisms that may have produced them in particular contexts (30). A total of 52 CMOcs were generated from the literature and 36 from the interview data. \u0026nbsp; These were compared across data sources to identify demi-regularities, i.e., any recurring alignments or complimentary, but not universal patterns in how certain contexts and mechanisms tended to produce similar outcomes. This process brought the two analyses together and enabled integration of insights from the literature and interviews. CMOcs from both data sets were triangulated to ensure that theory development remained grounded in empirical evidence and the contextual \u0026nbsp;experiences of MWC users and trainers. \u0026nbsp;Triangulation also \u0026nbsp;supported the refinement, \u0026nbsp;validation and prioritisation of CMOcs into IPTs. \u0026nbsp;Through this process, 16 IPTs were developed, representing early evidence-informed explanations of how manual wheelchair training might work, for whom and in what circumstance (19). Supplementary Material 1 details these IPTs and the data sources they were derived from. \u0026nbsp;Microsoft Excel was used to record and track CMOcs and their contribution to IPT development. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExisting theoretical frameworks relevant to rehabilitation and learning were also drawn upon to enhance the explanatory power of IPTs by supporting the interpretation of underlying mechanism in MWC training. Self-determination theory (31) helps explain how users become motivated to engage in wheelchair training when their needs for autonomy, competence and relatedness are supported. Situated learning theory (32) provides insight into how learning is most effective when embedded in authentic environments. Social cognitive theory (33) offered a lens to understand how individuals develop self-efficacy and confidence in their ability to perform wheelchair skills through mastery experiences, observational learning and social feedback. \u0026nbsp;Social learning theory (34) contributed to understanding how users learn through observation and modelling, such as when working alongside peers or trainers. Finally, cognitive load theory (35), was used to understand how the complexity of tasks and the presentation of information can impact learning new or demanding wheelchair skills \u0026nbsp; These theories helped \u0026nbsp;guide the refinement of IPTs and supported the prioritisation of the most plausible theories while discarding those less strongly supported. This process facilitated the transition from initial program theories to five \u0026nbsp;preliminary MRTs. \u0026nbsp;Figure 3 \u0026nbsp;Illustrates the refinement of an early theory through its development into an IPT and subsequently a MRT.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eInterview Data\u003c/h2\u003e\u003cp\u003eSeventeen people from four states and one territory of Australia, participated in semi structured interviews. Six were MWC users (4F, 2M), with an average age of 55.5\u0026thinsp;\u0026plusmn;\u0026thinsp;14.74 years, with experience in MWC use ranging from three to over 15 years (average 6.25\u0026thinsp;\u0026plusmn;\u0026thinsp;4.53). Reasons for MWC use included lower limb amputations (n\u0026thinsp;=\u0026thinsp;3), multiple contributing conditions (n\u0026thinsp;=\u0026thinsp;2) and post-polio syndrome (n\u0026thinsp;=\u0026thinsp;1). Eleven were MWC trainers (9F, 2M) with experience in MWC training ranging from four to over 30 years. The majority were occupational therapists (n\u0026thinsp;=\u0026thinsp;6), followed by peer wheelchair trainers (n\u0026thinsp;=\u0026thinsp;3), an exercise physiologists (n\u0026thinsp;=\u0026thinsp;1) and an allied health assistant (n\u0026thinsp;=\u0026thinsp;1). The trainers predominantly provided their service to adult MWC users, including those with neurological conditions, amputations, orthopaedic injury and Spinal Cord Injury (SCI). All participants were assigned a pseudonym, which is used in reporting the findings. Full demographic details of participant groups have been reported in detail in a separate study (6).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eLiterature\u003c/h2\u003e\u003cp\u003eThe 47 included papers were published between 2001 and 2024 across 12 countries, largely from North America (United States\u0026thinsp;=\u0026thinsp;16 and Canada\u0026thinsp;=\u0026thinsp;17). Papers included Randomized Control Trials (RCTs) (n\u0026thinsp;=\u0026thinsp;24); Pre and Post Design (n\u0026thinsp;=\u0026thinsp;9); qualitative papers (n\u0026thinsp;=\u0026thinsp;5), cohort studies (n\u0026thinsp;=\u0026thinsp;5), mixed methods (n\u0026thinsp;=\u0026thinsp;2) and case studies (n\u0026thinsp;=\u0026thinsp;2). Diverse groups of MWC user cohorts included people with SCI, Multiple Sclerosis (MS), Cerebral Palsy, Osteoarthritis (OA), Stroke, amputations and other conditions and included male and females who were both relatively inexperienced in MWC use or were long term MWC users with many years of experience. A range of MWC training programs were provided across papers. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e provides full details of study characteristics.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eStudy characteristics of included papers\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAuthor\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePublication Date\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCountry of Publication\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eType of Paper\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eParticipant details\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTraining Program\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBeaudoin et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCanada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMixed Methods\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19 participants (9M, 10F)\u003c/p\u003e\u003cp\u003eAverage age 45 years\u003c/p\u003e\u003cp\u003e14 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use include; MS, SCI, Amputation, spina bifida, other.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eRoulez avec confiance (RAC) OR Wheeling with Confidence\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBest et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2005\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCanada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20 participants (15M, 5F)\u003c/p\u003e\u003cp\u003eAverage age 49 years\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;1 year MWC experience\u003c/p\u003e\u003cp\u003eReasons for use include; amputations, stroke, peripheral neurological disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWheelchair skills training program\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBest et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCanada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e28 participants (22M, 6 F)\u003c/p\u003e\u003cp\u003eAverage age 48.7 years\u003c/p\u003e\u003cp\u003e13.6 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use include; MS, SCI, CP, other.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSelf-Efficacy Enhanced Wheelchair Training Intervention (WheelSee)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlouin et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCanada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCohort Study\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18 participants (16M, 2F)\u003c/p\u003e\u003cp\u003eAverage age 42.4 years\u003c/p\u003e\u003cp\u003e14.8 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use include; SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWheelchair Simulator with Haptic feedback\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChaar \u0026amp; Archambault\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCanada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eQualitative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6 participants (5M, 1F)\u003c/p\u003e\u003cp\u003eAverage age 56 years\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;3 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for MWC use; unspecified\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWheelchair simulator using a sidewalk scenario\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharlton et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAustralia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMixed Methods\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11 participants (9M, 2F)\u003c/p\u003e\u003cp\u003eAverage age 58.7 years\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;2 months MWC experience\u003c/p\u003e\u003cp\u003eReasons for use include; amputations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eModified version of the wheelchair skills training program.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8 participants (7M, 1 F)\u003c/p\u003e\u003cp\u003eAverage age 47.5years\u003c/p\u003e\u003cp\u003e16 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use include; MS, SCI, CP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eClinical Practice Guidelines for preserving shoulder function.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChoi et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eKorea\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePre and Post\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 participants (2M, 2F)\u003c/p\u003e\u003cp\u003eAverage age 47.2 years\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;1 year MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTraining across six skills; ascending/descending low and high curbs and ascending and descending stairs.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDeGroot et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2009\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCohort Study\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9 participants (6M, 3F)\u003c/p\u003e\u003cp\u003eAverage age 36.8 years\u003c/p\u003e\u003cp\u003e10 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; MS, SCI, CP, other\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBiomechanical efficiency training on a wheelchair treadmill, carpeted surface, ramp and cross slope.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDesai et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIndia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePre and Post design\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13 participants (6M, 3F)\u003c/p\u003e\u003cp\u003eAverage age unknown\u003c/p\u003e\u003cp\u003eUnknown years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWheelchair skills training program\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFurmaniuk et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePoland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePre and Post design\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e40 participants (40M)\u003c/p\u003e\u003cp\u003eAverage age 29.4 years\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;5 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eRugby skills group including muscle strength and endurance training and wheelchair skills.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGarrett et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2011\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCase Study\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 participants\u003c/p\u003e\u003cp\u003eAverage age unknown\u003c/p\u003e\u003cp\u003eunknown years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAdapted wheelchair skills training program.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGiesbrecht \u0026amp; Miller\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCanada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18 participants (15M, 5F)\u003c/p\u003e\u003cp\u003eAverage age 66.1 years\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;2 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; unknown\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eEnhancing Participation in the Community (EPIC Wheels)- monitored wheelchair training via a computer tablet.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGiesbrecht \u0026amp; Miller\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCanada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18 participants (13M, 5F)\u003c/p\u003e\u003cp\u003eAverage age 65 years\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;2 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; MS, SCI, amputation, OA, stroke\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eEnhancing Participation in the Community (EPIC Wheels)- monitored wheelchair training via a computer tablet.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGiesbrecht et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCanada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePre and Post design\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 participants (2M)\u003c/p\u003e\u003cp\u003eAverage age 66 years\u003c/p\u003e\u003cp\u003e20 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI, amputation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eEnhancing Participation in the Community (EPIC Wheels)- monitored wheelchair training via a computer tablet\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGiesbrecht et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCanada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eQualitative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10 participants (7M, 3F)\u003c/p\u003e\u003cp\u003eAverage age between 55\u0026ndash;85 years\u003c/p\u003e\u003cp\u003e4\u0026ndash;60 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; Unknown\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGiesbrecht et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCanada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e50 participants (17 M, 33F)\u003c/p\u003e\u003cp\u003eAverage age 52 years\u003c/p\u003e\u003cp\u003e7.8 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; Not stated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTEAM Wheels- monitored wheelchair training via a tablet\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHan et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eJapan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCohort Study\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12 participants (10M, 2F)\u003c/p\u003e\u003cp\u003eAge not specified\u003c/p\u003e\u003cp\u003eYears of MWC experience not specified\u003c/p\u003e\u003cp\u003eReasons for use not specified\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eThe use of sensors to help users visualise wheelchair operation techniques\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKirby et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCanada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e42 participants (10M, 32F)\u003c/p\u003e\u003cp\u003eAverage age 30 years\u003c/p\u003e\u003cp\u003e30 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI, amputation, able bodied persons\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTraining in wheelie related skills\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKirby et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2004\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCanada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePre and Post design\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24 participants- caregivers (9M, 15F)\u003c/p\u003e\u003cp\u003eAverage age 53.3 years\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;1 years MWC caregiver experience\u003c/p\u003e\u003cp\u003eReasons for use of user; amputation, MSK conditions, SCI, stroke\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWheelchair skills training program adapted for caregivers.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKirby et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e106 participants (101M, 5F)\u003c/p\u003e\u003cp\u003eAverage age 39 years\u003c/p\u003e\u003cp\u003e17.4 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWheelchair Skills Training Program\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKirby et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCanada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e27 participants- caregiver (6M, 6F)\u003c/p\u003e\u003cp\u003eAverage age caregiver 56.8 years\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;1 years MWC caregiver experience\u003c/p\u003e\u003cp\u003eReasons for use of user; Stroke, amputation, other\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eRemote training provided using the Wheelchair Skills Program Manual Version 5.1 for guide.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKotajarvi et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2006\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCohort Study\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18 participants (16M, 2F)\u003c/p\u003e\u003cp\u003eAverage age 38.4 years\u003c/p\u003e\u003cp\u003e14 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBiomechanical efficiency training with visual feedback\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLimroongreungrat et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2009\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e28 participants\u003c/p\u003e\u003cp\u003eAverage age 33.9 years\u003c/p\u003e\u003cp\u003eunknown years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWheelchair propulsion training with video feedback\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiu et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eQualitative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10 participants (6M, 4F)\u003c/p\u003e\u003cp\u003eAverage age 37.5 years\u003c/p\u003e\u003cp\u003e25.56 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; spina bifida, SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMy Wheelchair Guide app\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMacPhee,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2004\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCanada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e35 participants (26M, 9F)\u003c/p\u003e\u003cp\u003eAverage age 59 years\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;1 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; MSK and Neurological conditions.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWheelchair skills training program\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMcClure et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e31 participants (21M, 10F)\u003c/p\u003e\u003cp\u003eAverage age 41.4 years\u003c/p\u003e\u003cp\u003eUnknown years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eImplementation of clinical practice guidelines \"Preservation of Upper Limb Function Following Spinal Cord Injury\"\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiller et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCanada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18 participants (7M, 11F)\u003c/p\u003e\u003cp\u003eAverage age 66.2 years\u003c/p\u003e\u003cp\u003e4.3 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI, amputation, other\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWheelchair Self-Efficacy Enhanced for Use (WheelSeeU) training program\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMorgan et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePre and Post design\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6 participants (4M, 2F)\u003c/p\u003e\u003cp\u003eAverage age 38 years\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;2 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWheelchair Propulsion biomechanical training\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOzturk et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2011\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTurkey\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24 participants (11M, 13F)\u003c/p\u003e\u003cp\u003eAverage age 33 years\u003c/p\u003e\u003cp\u003e8.85 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI, amputation, OA, CP, Polio, stroke, other\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWheelchair Skills Training Program\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePark \u0026amp; Jung\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eKorea\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24 participants (14M, 10F)\u003c/p\u003e\u003cp\u003eAverage age 33 years\u003c/p\u003e\u003cp\u003e2 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; Stroke\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eModified Wheelchair skills training program\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePellichero\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCanada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eQualitative Research\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11 participants (3M, 8F)\u003c/p\u003e\u003cp\u003eAverage age 64.6 years\u003c/p\u003e\u003cp\u003e4.8 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; MS, SCI, amputation, OA, polio\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWheelchair Self-Efficacy Enhanced for Use (WheelSeeU) training program\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuinones-Uriostegui et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMexico\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePre and Post design\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12 participants (10M, 2F)\u003c/p\u003e\u003cp\u003eAverage age 35.3 years\u003c/p\u003e\u003cp\u003e5.6 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWHO 8 step guidelines on the provision of manual wheelchairs in less resourced settings\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRice et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCase Study\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 participants (1M)\u003c/p\u003e\u003cp\u003eAverage age 35.6 years\u003c/p\u003e\u003cp\u003e11 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eManual wheelchair propulsion training program using visual feedback\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRice et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e27 participants (24M, 3F)\u003c/p\u003e\u003cp\u003eAverage age 40.4 years\u003c/p\u003e\u003cp\u003e17.9 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eManual wheelchair propulsion training program using visual feedback\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRice et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14 participants (4M, 10F)\u003c/p\u003e\u003cp\u003eAverage age 40.4 years\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;17 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; MS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eManual wheelchair propulsion training\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRice et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2014\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37 participants (28M, 9F)\u003c/p\u003e\u003cp\u003eAverage age 37 years\u003c/p\u003e\u003cp\u003eUnknown years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eImplementation of the Paralysed Veterans of America's Clinical Practice Guidelines for Preservation of Upper Limb Function\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRichter et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2011\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePre and Post design\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e31 participants (27M, 4F)\u003c/p\u003e\u003cp\u003eAverage age 34.1 years\u003c/p\u003e\u003cp\u003e15 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI, CP, other\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBiomechanical wheelchair propulsion training using biofeedback.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRouthier et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCanada\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e39 participants (27M, 12F)\u003c/p\u003e\u003cp\u003eAverage age 46 years\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;1 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; MS, SCI, amputation, other\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFrench-Canadian version of the Wheelchair Skills Training Program\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStandal et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNorway\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eQualitative Research\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20 participants (16M, 4F)\u003c/p\u003e\u003cp\u003eAverage age 43 years\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;1 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI, Neurological condition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWheels in Motion training program.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTasiemski, et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMorocco\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePre and Post design\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19 participants (13M, 6F)\u003c/p\u003e\u003cp\u003eAverage age 33 years\u003c/p\u003e\u003cp\u003e24 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI, CP, polio, other\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWheelchair Skills and Empowerment Camp\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTasiemski et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePoland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCohort Study\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e122 participants (88M, 34 F)\u003c/p\u003e\u003cp\u003eAverage age 34 years\u003c/p\u003e\u003cp\u003e2 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use: SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAttendance at Active Rehabilitation Camps with focus on wheelchair skills\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVan Der Scheer et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNetherlands\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16 participants (11M, 5F)\u003c/p\u003e\u003cp\u003eAverage age 54 years\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;10 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLow-intensity wheelchair propulsion training.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVan Der Scheer et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNetherlands\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e29 participants (22M, 7F)\u003c/p\u003e\u003cp\u003eAverage age 56 years\u003c/p\u003e\u003cp\u003e18 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLow-intensity wheelchair propulsion training\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWorobey et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e79 participants (69M, 10F)\u003c/p\u003e\u003cp\u003eAverage age 40.5 years\u003c/p\u003e\u003cp\u003e13.2 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWheelchair skills training program.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYeo \u0026amp; Kwon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2018\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eKorea\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24 participants (19M, 5F)\u003c/p\u003e\u003cp\u003eAverage age 35 years\u003c/p\u003e\u003cp\u003e2.85 years MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWheelchair skills training program.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYong Tai et al.,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18 participants (12M, 6F)\u003c/p\u003e\u003cp\u003eAverage age 34 years\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;2 months MWC experience\u003c/p\u003e\u003cp\u003eReasons for use; SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLearning three wheelchair skills; ramps, wheelie and kerbs using video feedback.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eMiddle Range Theories:\u003c/h2\u003e\u003cp\u003eFive MRTs were developed through the synthesis of multiple, interrelated CMOcs, reflecting the complex and dynamic nature of MWC training. Rather than following a single, linear logic chain, these theories recognize that multiple mechanisms can be activated in a particular context, and that the outcomes are often shaped by a constellation of interacting mechanisms working together. Four of the MRTs were developed from a combination of literature and interview data and one from interview data alone (MRT 4). Self-Determination theory (31) helped explain the basis of multiple MRTs (MRT 1,2,4 and 5), as well as Social Cognitive Theory (36) (MRT 1, 3, 4 and 5), Cognitive load theory (35) (MRT 1, 2, 3), Social Learning Theory (34) (MRT 5) and Situated Learning Theory (32) (MRT 3). The five MRTs will be presented using the following headings; Resources and Training, Safe and Realistic environments, Peer and Social Support, Social Attitudes, Person Centred/Goal Driven Training. The MRTs and their alignment to relevant learning/rehabilitation theory are depicted in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e as \u003cem\u003eif-then-because\u003c/em\u003e statements to clearly articulate the causal logic underpinning each theory.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMiddle Range Theories presented as if-then-because statements alongside relevant learning and rehabilitation theories.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle Range Theory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIf-then-because statement\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAssociated learning or rehabilitation theory\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResources and training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eIf\u003c/b\u003e manual wheelchair training is supported by adequate healthcare resources, including access to appropriate equipment and skilled trainers,\u003c/p\u003e\u003cp\u003e\u003cb\u003ethen\u003c/b\u003e users are more likely to receive suitable wheelchairs and effective training,\u003c/p\u003e\u003cp\u003e\u003cb\u003ebecause\u003c/b\u003e well-resourced services enable personalised support that builds confidence through mastery experiences, which promotes skill development, supports safe use, and facilitates community participation.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSocial Cognitive theory, Self-determination theory, Cognitive load theory\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerson centred/goal driven trainings\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eIf\u003c/b\u003e manual wheelchair training is collaboratively tailored to an individual\u0026rsquo;s needs and goals rather than using a one-size-fits-all approach,\u003c/p\u003e\u003cp\u003e\u003cb\u003ethen\u003c/b\u003e users experience increased empowerment and motivation,\u003c/p\u003e\u003cp\u003e\u003cb\u003ebecause\u003c/b\u003e personalised training fosters a sense of ownership and relevance, leading to greater satisfaction, improved confidence, and more effective achievement of wheelchair use goals.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSelf-determination theory, Cognitive load theory\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSafe and authentic environments\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eIf\u003c/b\u003e manual wheelchair training is delivered in environments that balance physical safety with real-world relevance,\u003c/p\u003e\u003cp\u003e\u003cb\u003ethen\u003c/b\u003e users are more likely to develop confidence and self-efficacy in their wheelchair use,\u003c/p\u003e\u003cp\u003e\u003cb\u003ebecause\u003c/b\u003e practicing in settings that feel both safe and contextually meaningful supports psychological readiness, skill generalisation, and community participation.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSituated learning theory, Social cognitive theory, Cognitive load theory.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial attitudes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eIf\u003c/b\u003e wheelchair trainers, family, and friends perceive manual wheelchair (MWC) training as a pathway to independence,\u003c/p\u003e\u003cp\u003e\u003cb\u003ethen\u003c/b\u003e users are more motivated, develop greater acceptance of MWC use, and demonstrate improved skill acquisition and wheelchair use,\u003c/p\u003e\u003cp\u003e\u003cb\u003ebecause\u003c/b\u003e positive expectations and encouragement from significant others enhance motivation and reinforce the value of skill development.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSelf-determination theory, Social cognitive theory\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePeer and social support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eIf\u003c/b\u003e manual wheelchair training incorporates trusted social supports, such as peer mentors, fellow wheelchair users, and family or caregivers,\u003c/p\u003e\u003cp\u003e\u003cb\u003ethen\u003c/b\u003e users are more likely to experience psychological safety, increased motivation, and stronger self-efficacy,\u003c/p\u003e\u003cp\u003e\u003cb\u003ebecause\u003c/b\u003e trusted relationships foster emotional support, relatable role modelling, and shared learning, which together build confidence, independence, and acceptance of wheelchair use.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSelf-determination theory\u003c/p\u003e\u003cp\u003eSocial learning Theory\u003c/p\u003e\u003cp\u003eSocial cognitive theory\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eMRT 1: Resources and Training\u003c/h2\u003e\u003cp\u003eWhen MWC training is limited by healthcare resource constraints, users often receive unsuitable wheelchairs and inadequate training on wheelchair use. This undermines their confidence and- hampers skill development which restricts community participation and increases the risk of injury.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eI was just literally given the chair and said \u0026ldquo;Go for your life\u0026rdquo;. (Michelle- MWC user)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eReiterating the importance of resources, MWC trainers emphasised that appropriate equipment is needed for training to be effective.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo; So if you don't have the right equipment, or you've got a clunky old wheelchair, there's only so much that anyone can do. So having a wheelchair that's a good fit and set up efficiently, I think, helps promote wheelchair skills, because otherwise it makes it too hard, and then people can't do it.\u0026rdquo; (Kristen- MWC Trainer)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn contexts where individuals had access to MWCs that were prescribed, fitted and set up for their needs, the risk of injury is reduced, and users experience greater confidence, improved wheelchair skills and increased MWC use (12, 37\u0026ndash;41). These outcomes are likely linked to enhanced physical stability and control afforded by well-matched equipment. MWC users and trainers also identified resource constraints and funding limitations reduced the scope and quality of training provided. This was particularly noted in acute settings where time, staffing and environmental limitations impact on training offered. Pheobe, a MWC trainer reflected on this;\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think ideally we should be teaching people how to go up and down curbs and how to manoeuvre a wheelchair on uneven terrain outside, or if there's a camber on the footpath, I can pretty confidently say we don't ever do that in the acute setting.\u0026rdquo; (Pheobe- MWC trainer)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eResource constraints lead to user\u0026rsquo;s having limited MWC skills and decreased confidence in MWC use, negatively impacting on community participation and engagement and increasing a users\u0026rsquo; injury risk.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It got to the stage that I didn't feel safe, and I didn't feel comfortable [in the MWC]. So I then, you know, forced myself, when I went out in the public to use my walking sticks. So that puts me at an increased risk of falls.\u0026rdquo; (Chris- MWC user)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn addition to resource constraints, MWC trainers highlighted a lack of guidance on training design and service delivery. In the absence of clear guidance, trainers relied heavily on personal experience, leading to inconsistent training quality. MWC users identified this led to suboptimal outcomes, including increased injury risk and user dependency for community participation. MWC Trainers expressed a need for structured guidance to support consistent practice. As Francesca, a MWC user noted;\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think something like a simple form \u0026hellip; it should be almost ticked off regularly, rather than just being the informal training which may vary depending who's teaching it\u0026rdquo; (Francesca- MWC Trainer)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e Structured programs and clinical guidelines for MWC training provide a supportive framework that enhances trainer confidence, promotes consistent instruction, and improves skill acquisition and propulsion technique among users (3, 4, 40, 42).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eMRT 2: Person Centred and Goal Driven Training\u003c/h2\u003e\u003cp\u003eWhen MWC training is collaboratively tailored to individual needs and goals it empowers and motivates users, leading to greater satisfaction with training, improved confidence and more effective wheelchair related goal achievement (12, 37, 42\u0026ndash;53). Trainers noted that when training was meaningful and relevant, users were more engaged in training.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think one of the things that works there is making the task functional. If they want to go to the shop, if you can tie it in.\u0026rdquo; (Francesca- MWC trainer)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTaking a scaffolded approach to skill development, where task complexity is adjusted to match a users\u0026rsquo; capacity, is especially important for MWC users with chronic or progressive conditions (10, 12, 47, 54\u0026ndash;57). This approach supports management of cognitive load, reduces overwhelm, and fosters control and empowerment (35). Trainers noted that having a clear goal pathway increases motivation and engagement in training.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You know, you wanna get there. You might not be able to do that yet, because that involves going up a step, and you haven't got that yet. But if you can work on this and then this, and then this, you can get to that point.\u0026rdquo; (Vince- MWC Trainer)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAdditionally, planning training that is self-paced and tailored to individual learning preferences enhances confidence, motivation and engagement (58). Trainers highlighted the Importance of adapting communication and teaching strategies to the user\u0026rsquo;s cognitive abilities and health literacy needs.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Some of the older population, generally sort of like seventies and above, or if they have lower levels of health literacy, you can kind of talk till the cows come home. But you can just tell that they're not understanding what you mean.\u0026rdquo; (Pheobe-MWC Trainer)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIncorporating real time and retrospective visual feedback, such as video review or propulsion metrics also supports users\u0026rsquo; understanding and engagement (59). These tools help users to see their propulsion technique, encourage self-reflection and promote active involvement in their training, leading to improved consistency and efficiency with wheelchair propulsion (60\u0026ndash;64).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eMRT 3: Safe and authentic environments\u003c/h2\u003e\u003cp\u003eWhen MWC training is delivered in environments that balance physical safety with contextual relevance, MWC users are more likely to develop confidence and self-efficacy leading to increased community MWC use. MWC skills and independence are supported when training occurs in predictable, low risk environments (12, 42, 43, 65). Such settings minimise injury and anxiety, while fostering self-efficacy. Gradually increasing environmental demands supports skill attainment and confidence, making users more likely to persist through challenges. MWC users and trainers recognised the value of starting in controlled, indoor environments before transitioning to less predictable outdoor settings.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We've got a 10 centimeter platform step and we've got obstacles that we can put up to learn the basics like caster flicks in ascending and descending a step\u0026hellip;\u0026hellip;\u0026hellip; I find teaching those skills in a closed environment much easier\u003c/em\u003e [to complete first] \u003cem\u003ebefore transitioning to the community.\u0026rdquo; (MWC Trainer-Laura)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWheelchair simulators (66) offer another way to introduce environmental complexity in a safe, controlled manner (4, 61). Simulation based training can enhance engagement and confidence while supporting skill transfer across varied settings through repeated, low risk practice. However, while safe environments were identified as being important, both MWC users and trainers emphasised that a sense of safety alone was not sufficient to ensure effective learning and long-term independence. Frank, a MWC user reflected;\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The initial training in a hospital if you are just in a safe environment. You're only ever gonna expect it to be safe. And life's not like that.\u0026rdquo; (Frank- MWC user)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eParticipants emphasised the importance of training in environments that reflect everyday settings and challenges MWC users are likely to encounter. One MWC trainer illustrated this idea;\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u003c/em\u003e [training in environments the MWC will be used in] \u003cem\u003ehelps them\u003c/em\u003e [MWC users] \u003cem\u003eto see what kind of challenges they might have, because often they'll say, Oh, I'll be fine. I'll be able to do that. But actually, when they go to do it, there's all these barriers that they haven't thought about.\u0026rdquo; (MWC Trainer- Bianca)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMultiple papers incorporated training in community settings, such as shops and public gardens, recognising that practicing in familiar, meaningful environments boosts confidence and enhances satisfaction with training, leading to increased wheelchair use and community participation, which positively influences quality of life, (44, 48, 57, 67, 68). Without this training, users may rely upon trial-and-error style learning, increasing their risk of adverse events (12). MWC users also reported that limited community -based training reduced their confidence to access the community, increasing dependence on caregivers, which is particularly problematic when care partners were not included in the training process.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eMRT 4: Social Attitudes\u003c/h2\u003e\u003cp\u003eWhen individuals face mobility loss that necessitates starting MWC use, they can internalize societal attitudes that value walking as a symbol of independence. In this context the wheelchair can be seen as a symbol of disability, triggering feelings of shame, reluctance or pessimism towards wheelchair use.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Part of that emotional journey is the shame that you feel, the embarrassment that you feel to start off with.\u0026rdquo; (Chris- MWC user)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThis challenge is often compounded by the attitudes of some healthcare professionals and trainers in hospital settings, who may prioritize mobility-related outcomes such as walking over wheelchair training. As a result, engagement in MWC training is low and can limit a MWC users\u0026rsquo; adjustment and effective MWC use.\u003c/p\u003e\u003cp\u003eCultural expectations and stereotypes, particularly about what older MWC users are capable of, can also undermine confidence and willingness to engage in training (12). These stereotypes often portray older adults as frail, dependent, or less able to learn new skills, which can lead to users and trainers having lowered expectations for training outcomes. Such assumptions may create psychological barriers that result in fewer opportunities for skill development, hindering meaningful participation in wheelchair use.\u003c/p\u003e\u003cp\u003eWhen wheelchair trainers, family and friends view MWC training as a crucial step towards a user gaining independence in everyday living and community engagement, their positive attitudes and encouragement influence the users\u0026rsquo; motivation and acceptance of wheelchair use. This helps the user engage more fully in training, leading to improved skill acquisition and greater confidence in using the wheelchair. This was reflected by Francesca, MWC trainer;\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Family and friends relationships make a big difference. If family and friends are very positive about wheelchair use, then that patient is more motivated.\u0026rdquo; (Francesca- MWC trainer)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eMRT 5: Peer and Social Support\u003c/h2\u003e\u003cp\u003eMWC users experience greater psychological safety, motivation and self-efficacy when training incorporates trusted social supports, such as peer mentors, peer wheelchair users and family or caregivers. These mechanisms enhance confidence, foster independence and support greater acceptance of wheelchair use.\u003c/p\u003e\u003cp\u003eThe presence of caregivers during training provided emotional reassurance and practical encouragement, enabling users to feel safer and more willing to attempt new skills (48, 68).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We don\u0026rsquo;t do it that much\u003c/em\u003e, [incorporate caregivers into training] \u003cem\u003ebut you know, it would make them feel more comfortable if they've got a family member there.\u0026rdquo; (Libby- MWC trainer)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eGroup and peer led training models are associated with improved engagement (54), greater confidence in wheelchair skills and increased participation in activities of daily living (42, 43, 69). MWC users and trainers noted that shared lived experiences triggered mechanisms such as camaraderie, belonging and psychological safety, enhancing the training experience (12, 48). This finding was highlighted by Hannah, a MWC trainer;\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;A sense of safe space connectedness to other people and feeling supported by each other, learning together all those lovely things that come with a group dynamic.\u0026rdquo; (Hannah- MWC trainer)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eGroup training introduces fun and social interaction into the learning process, making training feel less clinical and more engaging. This atmosphere increases MWC users\u0026rsquo; motivation and willingness to participate (12, 52) and allows for social learning (34), where individuals acquire new skills by watching others. Additionally, witnessing peers succeed serves as a powerful source of vicarious motivation (36), boosting users\u0026rsquo; confidence and belief in their own ability to improve.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;One of the things that's really vital is having trainers who are wheelchair users themselves\u0026hellip;. you have so much cultural capital going into the room.\u0026rdquo; (Vince-MWC trainer)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWhen MWC users are trained by peers with lived experience or watch videos of skills being performed, they are not only shown how to perform wheelchair skills but are also offered insight into what is possible. This supports user confidence, positively impacting on skill acquisition (12, 39, 45\u0026ndash;47, 56, 61, 70\u0026ndash;73). Modelling often offers reassurance that goals are achievable and provides a clear understanding of what is expected, helping to reduce anxiety and support self-efficacy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Having someone show you is important\u0026hellip;.when you're actually sitting in a chair, it's a different kettle of fish.\u0026rdquo; (Michelle- MWC user)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eGroup-based training also provides opportunity to observe, compare and reflect on different approaches to wheelchair use, helping MWC users to refine their own techniques. This shared learning environment can lead to improved skill acquisition and greater confidence in MWC use. However, in some cases users reported reduced confidence when there was a large skill disparity between themselves and others, which triggered lower self-efficacy (49).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eLinks to established theory\u003c/h2\u003e\u003cp\u003eThese MRTs align with established learning and rehabilitation theories, which explain how and why the proposed mechanisms may work. When MWC training is supported by adequate health resources (MRT1 ) and collaboratively tailored to an individuals\u0026rsquo; needs and goals (MRT 2), the mechanisms that lead to increased skill acquisition and wheelchair use can be supported by self-determination theory (31), whereby access to personalised training allows choice over training, supports training ownership and fosters a sense of competence, leading to increased motivation to enhance skill development. Access to trained staff and appropriate equipment also creates opportunities for successful experiences and modelling, which strengthens self-efficacy, positively influencing skill acquisition (social cognitive theory (36)). Additionally, having well-resourced training which is aligned to the users\u0026rsquo; needs means that training can be catered to the right level of challenge enabling more efficient learning and wheelchair use (cognitive load theory (35)).\u003c/p\u003e\u003cp\u003eA graduated increase in the environmental complexity of training as outlined in MRT 3, scaffolds cognitive load related to new skill learning. More structured training environments reduce extrinsic cognitive load, permitting more efficiency in learning new skills, with transfer to more complex environments permitting the development of schematic complexity (cognitive load theory(35)). At the same time, practicing in meaningful settings strengthens learning by enabling users to perform everyday tasks, receive feedback and build self-efficacy though successful experiences (social cognitive theory (36), situated learning theory (32)). Embedding training in environments that reflect users\u0026rsquo; daily contexts not only supports motivation and confidence but also promotes skill generalisation and sustained engagement.\u003c/p\u003e\u003cp\u003eWhen wheelchair peers and care partners are incorporated into MWC training (MRT 5) and when trainers, family and peers hold positive attitudes towards MWC training (MRT 4) the resulting psychological safety and social reinforcement enhance skill acquisition and community participation. These outcomes are supported by Social Learning Theory (34), where learning is shaped through observation and modelling, and by Social Cognitive Theory (36), which highlights the role of self-efficacy, developed through social encouragement and vicarious experiences. Additionally, self-determination theory (31) explains how environments that foster autonomy, relatedness and competence, such as those that integrate trusted social supports, promote intrinsic motivation and engagement in training.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis research presents the outcomes of a realist synthesis designed to explain how and why manual wheelchair training works for individuals who commence wheelchair use due to chronic or progressive conditions. Drawing on literature and qualitative interviews with MWC users and trainers and guided by existing rehabilitation and learning theories, five MRTs were developed. These MRTs offer generalisable causal explanations of the mechanisms through which MWC training leads to positive outcomes. Collectively they reflect the importance of a well -resourced, user-centred, socially supportive and contextually relevant approach to MWC training.\u003c/p\u003e\u003cp\u003eAccess to well fitted equipment, trained personnel and dedicated training time is critical to developing MWC users\u0026rsquo; confidence and proficiency (MRT 1). However, this research highlights persistent challenges in accessing MWC training for individuals with chronic and progressive conditions. Current funding structures are heavily weighted towards hospital-based services (74), where younger individuals with traumatic injuries are more likely to receive well-resourced training support. In contrast, those with chronic or progressive conditions often acquire a wheelchair through community pathways or are transitioned more rapidly out of hospital care without structured training, reflecting a system poorly aligned with the needs of people with gradual functional decline.\u003c/p\u003e\u003cp\u003eThese inequities are shaped by institutional ageism (75), where service pathways and funding models tend to prioritise younger populations, while undervaluing the mobility needs of older adults (76, 77). In response to calls for greater consumer choice and control, health and disability systems are increasingly adopting individualized funding models that allow users to decide which services best meet their needs. However, these models also present challenges. Consumers often face complex navigation processes, leading to long delays in accessing and using allocated funds (78, 79) and can encounter limited availability of skilled service providers (79). As a result, individuals may be unable to access MWC training at the time they are in most need of it ie., during initial adjustment to wheelchair use or upon reintegration to the community. This reduces the potential impact of training on confidence, independence and community participation.\u003c/p\u003e\u003cp\u003eFragmentation across healthcare systems further impedes access to MWC training (80, 81). Acute, subacute and community services frequently operate in silos with limited communication and different priorities, leading to poorly coordinated care pathways. Inconsistent referral pathways contribute to missed opportunities for follow up training after hospital discharge. Hospital systems typically prioritise discharge efficiency and short-term functional outcomes, resulting in training that is either skill focused or omitted entirely (8, 9, 11, 81\u0026ndash;83). This limits the potential for training to be individualised, meaningful and goal directed, factors that are essential for supporting engagement (MRT 2).\u003c/p\u003e\u003cp\u003eHospital based training, while providing a controlled and safe environment for learning, offers limited opportunities for MWC users to practice wheelchair use in lived environments. As described in MRT 3, learning in authentic environments promotes confidence, skill generalisation and participation in daily life. Community based training, when available can support the easier integration of trusted social supports and caregivers into training, improving psychological safety and motivation. However, biomedical models dominate acute care, often overlooking factors that support psychosocial readiness including the lack of family inclusion within training. As emphasised in MRT 4, inclusive environments and positive social attitudes are essential for motivation and sustained participation. Without seamless transitions and cross sector communication, training will remain fragmented and unresponsive to users\u0026rsquo; lived realities.\u003c/p\u003e\u003cp\u003eThere is also limited governance and accountability for training standards. Professional organisations, including the International Society of Wheelchair Professionals (ISWP) and the WHO have developed certification tools (ie., ISWP Trainer certification (84)), frameworks (ie., WHO\u0026rsquo;s Eight Steps for Appropriate Wheelchair Provision (85)), guidelines (ie., WHO\u0026rsquo;s wheelchair provision guidelines (15), Paralyzed Veterans of America\u0026rsquo;s Clinical Practice Guideline for Preservation of Upper Limb Function Following a Spinal Cord Injury (14)) training programs (ie., WHO\u0026rsquo;s Basic and Intermediate Training Packages (86, 87)) and resources (ie., ISWP Wheelchair educators package (88)) to strengthen wheelchair service capacity globally. Additionally, the Wheelchair Skills Program (16) is a freely available evidence-based training package that strives to promote consistency and quality assurance in wheelchair training delivery. However, while these initiative demonstrate growing international commitment, there is currently no designated body responsible for governance or oversight to ensure MWC training is delivered consistently, equitably and to an acceptable standard (89).\u003c/p\u003e\u003cp\u003e Additionally, most of these resources provide general content guidance on skill development or biomechanical propulsion principles that are broadly applicable, yet they lack detailed strategies for tailoring training to diverse user needs or adapting it to the varied contexts in which training occurs. This gap is particularly important given the findings of MRT 2, which highlights the need for goal directed, individualised training, particularly for individuals adjusting to functional change due to chronic or progressive conditions. Without protocols that facilitate training that is responsive to the needs and contexts of the individual, such as flexible service models, scaffolded learning and individual goal setting, training risks becoming generic, disengaging or misaligned with the users\u0026rsquo; needs. Without defined service expectations, mechanisms to monitor training outcomes, or structured feedback and follow up processes, basic practice is not consistently upheld, and training quality remains variable. Embedding accountability within service agreements, across sectoral and service systems and using national guidelines and funding frameworks is essential to ensure training is delivered as a core component of care. This includes implementing provider responsibilities, performance indicators, and reporting systems to support quality assurance and drive improvement across the care continuum.\u003c/p\u003e\u003cp\u003eInclusive training environments also require attention, particularly given their importance in fostering user motivation and participation (MRT 4). A major challenge in delivering this is the current shortage of individuals trained in the delivery of inclusive MWC training. Initiatives such as the ISWP trainer certification represents important progress towards building a competent workforce, however their impact is limited due to voluntary uptake, cost barriers and lack of integration into local systems (89). Existing training also often prioritizes biomedical approaches ie. focuses on physical and technical aspects of wheelchair use, with less emphasis on psychosocial and environmental dimensions that are equally critical to the user. To address these gaps, it is essential to broaden the scope of training to include more affirming and inclusive models. Peer-led models may offer such affirming approaches (43, 48, 51\u0026ndash;54), as peer mentors provide emotional and practical support (90\u0026ndash;93), reinforce self-efficacy, and model positive wheelchair use, which is central to developing proficiency in wheelchair use (MRT 5)(90\u0026ndash;93).Strengthening workforce capabilities will require broader system level investment, including the upskilling assistive technology providers (6) and embedding MWC training more prominently within professional education programs (94, 95). Regardless of who is delivers training, all approaches must reflect inclusive and motivational practices that promote psychosocial wellbeing alongside skill development.\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eRecommendations and Implications for Practice\u003c/h2\u003e\u003cp\u003eCollectively, the MRTs developed in this research reinforce prior calls (81) for equity in wheelchair training. System-wide reforms are needed to ensure consistent access to equipment and training regardless of age, diagnosis or funding stream. Integrated funding models and coordinated care pathways across hospital, community, health, disability and aged care services are essential to support user-centred, goal directed training. Governance structures should include guidance for best practice training delivery and investment in workforce development. Strengthening accountability through outcome monitoring, referral expectations and cross sector coordination is critical. Seven key recommendations that operationalise these priorities are summarised in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. Their implementation would support equitable, responsive and effective MWC training for individuals with chronic and progressive conditions. Implementation of these recommendations must be accompanied by research that evaluates user outcomes, training effectiveness, and system-level impact.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSummary of key recommendations\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKey Recommendation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStrategies\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEquitable access to MWC training resources across care sectors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Address funding disparities between hospital and community-based services to ensure equitable access to training and equipment.\u003c/p\u003e\u003cp\u003e\u0026bull; Redesign funding models to better support people with chronic or progressive conditions who acquire wheelchairs outside of hospital settings\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntegrate services across healthcare sectors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Improve coordination between acute, subacute and community settings to support seamless care transitions.\u003c/p\u003e\u003cp\u003e\u0026bull; Develop consistent referral pathways to ensure access to follow up MWC training in the community\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMWC training is delivered in authentic and contextually relevant environments\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Training to transition from safe, controlled environments to lived environments to support skill generalisation, confidence and participation.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTraining environments must be psychologically safe and inclusive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Integrate peer mentors, care partners and trusted social supports into MWC training.\u003c/p\u003e\u003cp\u003e\u0026bull; Train staff to deliver inclusive, affirming care that recognises psychosocial and environmental influences.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProvision of flexible, person-centred training delivery.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Create flexible service models that that emphasise individualised training approaches.\u003c/p\u003e\u003cp\u003e\u0026bull; Provide practical tools and frameworks to support training personalisation of MWC training and alignment with user goals.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBuild workforce Capacity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Develop workforce strategies to ensure sufficient and skilled personnel to deliver MWC training across settings.\u003c/p\u003e\u003cp\u003e\u0026bull; Incorporate MWC training into professional education programs and promote skill development for clinicians and assistive technology providers.\u003c/p\u003e\u003cp\u003e\u0026bull; Invest in peer-led models of training.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmbed accountability mechanisms for MWC training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Introduce system level accountability frameworks that define expectations for MWC training delivery.\u003c/p\u003e\u003cp\u003e\u0026bull; Include outcome performance indicators and service level reporting\u003c/p\u003e\u003cp\u003e\u0026bull; Clarify roles and responsibilities across sectors to ensure no aspects of MWC training are overlooked.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\u003cp\u003eThis research used a realist methodology to explore how and why MWC training interventions work, for who and under what conditions. Triangulation of systematic review data with stakeholder interviews, enhanced rigour and ensured findings were grounded in both evidence and lived experiences, to support the development of practical, theory-informed recommendations. Given interviews were completed with a small, Australian based sample only, the cultural and service generalisability of these findings may be limited. Additionally, the service assumptions and funding structures reflected in the discussion section of this research and subsequent recommendations are most applicable to middle and high-income contexts with established healthcare and rehabilitation systems. Further research is needed to explore how these findings might be adapted or applied in low resource settings.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis research developed five MRTs that explain how and why MWC training interventions work for individuals who commence MWC use later in life due to chronic and progressive conditions. Findings emphasise the need for system level reforms to ensure training is person centred, contextually relevant and equitably delivered. Addressing gaps in funding, governance, workforce and accountability is essential to embed training as a core component of care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eABI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Acquired Brain Injury\u003c/p\u003e\n\u003cp\u003eAHA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; Allied Health Assistant\u003c/p\u003e\n\u003cp\u003eCMOc\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Context-Mechanism-Outcome configuration\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Exercise Physiologist\u003c/p\u003e\n\u003cp\u003eIPT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Initial Program Theory\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMWC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Manual Wheelchair\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMRT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Middle Range Theory\u003c/p\u003e\n\u003cp\u003eMS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Multiple Sclerosis\u003c/p\u003e\n\u003cp\u003eNSW\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;New South Wales\u003c/p\u003e\n\u003cp\u003eOT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Occupational Therapist\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRCT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Randomized Control Trial\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSCI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Spinal Cord Injury\u003c/p\u003e\n\u003cp\u003eUK \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;United Kingdom\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was conducted in accordance with the Declaration of Helsinki. Ethical approval for this study was obtained from the University of Adelaide Human Research Ethics Committee, approval number. H-2022-218. All participants provided informed consent prior to participation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during this research are available from the corresponding author on reasonable request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no funding received for this research\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors were responsible for conceptualization; methodology; writing—review \u0026amp; editing of this manuscript, KC was responsible for writing the original manuscript and for formal analysis and preparing all figures and tables. All authors contributed to interpretation of both datasets and SA, NL and CM were responsible for supervision. All authors have read and approved the final manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTu CJ, Liu L, Wang W, Du HP, Wang YM, Xu YB, et al. Effectiveness and safety of wheelchair skills training program in improving the wheelchair skills capacity: a systematic review. Clinical Rehabilitation. 2017;31(12):1573-82.\u003c/li\u003e\n\u003cli\u003eKeeler L, Kirby RL, Parker K, McLean KD, Hayden JA. Effectiveness of the Wheelchair Skills Training Program: a systematic review and meta-analysis. Disability \u0026amp; Rehabilitation: Assistive Technology. 2019;14(4):391-409.\u003c/li\u003e\n\u003cli\u003eChen P. 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Rehabilitation Psychology. 2006;51(4):289.\u003c/li\u003e\n\u003cli\u003eGassaway J, Jones ML, Sweatman WM, Hong M, Anziano P, DeVault K. Effects of Peer Mentoring on Self-Efficacy and Hospital Readmission After Inpatient Rehabilitation of Individuals With Spinal Cord Injury: A Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation. 2017;98(8):1526-34.e2.\u003c/li\u003e\n\u003cli\u003eBarclay L, Hilton GM. A scoping review of peer-led interventions following spinal cord injury. Spinal Cord. 2019;57(8):626-35.\u003c/li\u003e\n\u003cli\u003eThompson DM, Booth L, Moore D, Mathers J. Peer support for people with chronic conditions: a systematic review of reviews. BMC Health Services Research. 2022;22(1):427.\u003c/li\u003e\n\u003cli\u003eBurrola-Mendez Y, Kamalakannan S, Rushton PW, Bouziane SA, Giesbrecht E, Kirby RL, et al. 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Disabil Rehabil Assist Technol. 2020;15(5):553-6\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Manual wheelchair training, chronic conditions, progressive conditions, best practice, realist approach","lastPublishedDoi":"10.21203/rs.3.rs-7483544/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7483544/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eManual wheelchair (MWC) training is evidenced as a crucial intervention provided to many populations, however gaps in provision occur for individuals commencing wheelchair use in later life due to chronic and progressive conditions. Effective training can improve independence and engagement in meaningful activities and reduce injury risk, caregiver burden and reliance upon healthcare services. However, not all training contexts yield positive outcomes for all MWC users. Using a realist approach, this study describes the development of middle range theories to provide insight into the contexts and mechanisms that underpin successful manual wheelchair training outcomes.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethod\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA realist approach synthesised evidence from primary studies (n\u0026thinsp;=\u0026thinsp;47) and stakeholder interviews (n\u0026thinsp;=\u0026thinsp;17) to explore the contexts, mechanisms and outcomes underlying manual wheelchair training effectiveness. Retroductive analysis was used to build and refine initial program theories to explain why and under what circumstances a MWC training intervention may be working. To enhance explanatory power, we considered existing rehabilitation and learning theories, leading to the development of middle range theories that offer generalisable causal explanations of how and why MWC training works.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFive Middle-Range Theories (MRTs) were developed. MRT 1: Resources and structured guidance enhances user confidence; MRT 2: The delivery of person-centred, goal-directed training enhances motivation, user acceptance and engagement in MWC training; MRT 3: Training in safe and relevant environments facilitates MWC user confidence and willingness to engage in training. MRT4; Training in environments with positive social attitudes towards wheelchair use enhances psychological safety and acceptance of wheelchair use. MRT 5; Including peers, peer trainers and care partners in MWC training is motivational and supports self-efficacy in wheelchair use. Collectively these MRTs reflect the importance of a well -resourced, user-centred, socially supportive and contextually relevant approach to MWC training.\u003c/p\u003e\u003cp\u003e\u003cb\u003eDiscussion/Implications\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis research highlights the need for system-wide reform to improve MWC training for individuals with chronic and progressive conditions. Key priorities include addressing funding disparities, integrating services across sectors, delivering training in authentic, inclusive environments, providing flexible, person-centred approaches, building workforce capacity and embedding accountability into MWC training.\u003c/p\u003e","manuscriptTitle":"Manual wheelchair training for individuals with chronic and progressive conditions: A critical realist approach to improving practice","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-15 15:41:29","doi":"10.21203/rs.3.rs-7483544/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-03T06:12:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-01T19:38:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-30T03:04:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-26T19:37:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"32439039041095375016312849016654047633","date":"2025-09-10T14:19:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"138328337184216036409180258124967948447","date":"2025-09-08T22:20:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58415261254505942850424708272731936329","date":"2025-09-08T21:25:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-08T07:17:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-08T02:33:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-04T02:18:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-09-04T02:14:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"59232053-164e-43ee-b29b-7d4827307a21","owner":[],"postedDate":"September 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-05T16:00:13+00:00","versionOfRecord":{"articleIdentity":"rs-7483544","link":"https://doi.org/10.1186/s12913-025-13727-0","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-12-29 15:57:36","publishedOnDateReadable":"December 29th, 2025"},"versionCreatedAt":"2025-09-15 15:41:29","video":"","vorDoi":"10.1186/s12913-025-13727-0","vorDoiUrl":"https://doi.org/10.1186/s12913-025-13727-0","workflowStages":[]},"version":"v1","identity":"rs-7483544","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7483544","identity":"rs-7483544","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}